HOUSE OF LORDS
Science and Technology Committee
6th Report of Session 2006–07
Allergy
Volume II: Evidence
Ordered to be printed 24 July 2007 and published 26 September 2007
Published by the Authority of the House of Lords
London : The Stationery Office Limited £28.50
HL Paper 166-II
CONTENTS
Page
Oral Evidence Department of Health Written evidence from Department of Health, Health and Safety Executive, Department for Work and Pensions, Department for Education and Skills, Department for Communities and Local Government 1 Oral evidence (22 November 2006) 16 Supplementary written evidence from Department of Health 25
Health and Safety Executive, Department for Education and Skills, Department for Work and Pensions, Department for Communities and Local Government Oral evidence (22 November 2006) 26 Supplementary written evidence from Department for Work and Pensions 35
Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux, Professor John Warner Written evidence from Professor Peter Burney 37 Oral evidence (6 December 2006) 41 Supplementary written evidence from Professor Peter Burney 60
Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw, Professor Anthony Frew Written evidence from the British Society for Allergy and Clinical Immunology 62 Written evidence from the European Academy of Allergology and Clinical Immunology 66 Oral evidence (18 December 2006) 71
Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen, Professor John Westwick Oral evidence (18 December 2006) 82 Supplementary written evidence from the Medical Research Council 91
Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius, Dr David Orton Written evidence from Professor Anthony Newman Taylor 92 Written evidence from Professor Raymond Agius 93 Oral evidence (10 January 2007) 94 Supplementary written evidence from Professor Raymond Agius 111
Dr Mark Levy, Dr Susan Leech, Dr William Egner, Dr Pamela Ewan Written evidence from the Royal College of General Practitioners 112 Written evidence from the Royal College of Paediatrics and Child Health 115 Written evidence from the Royal College of Pathologists 120 Written evidence from the National Allergy Strategy Group 126 Oral evidence (17 January 2007) 131
Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch, Mr Les Bailey Written evidence from the Food Standards Agency 148 Oral evidence (31 January 2007) 159 Supplementary written evidence from the Food Standards Agency 169 Further Supplementary written evidence from the Food Standards Agency 170
Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey, Mrs Hazel Gowland Written evidence from the Anaphylaxis Campaign 170 Supplementary written evidence from the Anaphylaxis Campaign 179 Written evidence from Dr Richard Pumphrey 180 Oral evidence (31 January 2007) 180 Supplementary written evidence from Dr Richard Pumphrey 188
Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison, Mr Grant Ager Written evidence from the Chartered Institute of Environmental Health 190 Oral evidence (7 February 2007) 191
Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan, Professor Edzard Ernst Written evidence from the Society of Homeopaths 202 Written evidence from Professor Chris Corrigan 204 Oral evidence (21 February 2007) 208 Supplementary written evidence from the Society of Homeopaths 217
Dr Jean Monro, Dr Damien Downing, Mr Don Harrison, Professor Simon Wessely Written evidence from Dr Jean Monro 219 Written evidence from the British Society for Ecological Medicine 220 Written evidence from the British Institute for Allergy and Environmental Therapy 224 Written evidence from Professor Simon Wessely 227 Oral evidence (21 February 2007) 227 Supplementary written evidence from the British Society for Ecological Medicine 235 Supplementary written evidence from the British Institute for Allergy and Environmental Therapy 235
Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan, Dr Shuaib Nasser Written evidence from the British Association of Dermatologists 237 Oral evidence (28 February 2007) 238
Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer, Dr Mark Rosenthal Written evidence from Professor Jonathan Hourihane 252 Written evidence from Dr Mark Rosenthal 252 Oral evidence (7 March 2007) 253
Ms Joy Winks, Ms Sarah Day Oral evidence (7 March 2007) 265 Supplementary written evidence from the Royal College of Nursing 270
Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young, Mr Andrew Dillon Written evidence from Yorktest Laboratories Ltd 272 Oral evidence (15 March 2007) 273 Supplementary written evidence from Yorktest Laboratories Ltd 281 Supplementary written evidence from the Medicines and Healthcare products Regulatory Agency 283
Dr Glenis Scadding, Dr Clare Mills, Ms Donna Covey, Ms Lindsey McManus Written evidence from the Royal National Throat Nose and Ear Hospital 284 Written evidence from the Institute of Food Research 285 Written evidence from Asthma UK 288 Written evidence from Allergy UK 291 Oral evidence (15 March 2007) 294 Supplementary written evidence from Allergy UK 303
Mr Ivan Lewis MP, Department of Health Oral evidence (18 April 2007) 304 Supplementary written evidence from the Department of Health 320
Written Evidence Advertising Standards Authority 325 British Occupational Health Research Foundation 338 British Thoracic Society 341 Dr A T Clark and Dr P W Ewan 342 Coeliac UK 342 Faculty of Homeopathy 346 Royal College of Anaesthetists 350 Latex Allergy Support Group 351 The Patent Office 354 Research Councils UK 367 Royal College of Physicians 373 Royal Pharmaceutical Society of Great Britain 374 Royal College of Midwives 384 Wellcome Trust 385
The Committee’s Report drawing on this oral and written evidence is published as a separate volume, HL Paper 166-I. Minutes of Evidence
TAKEN BEFORE THE SELECT COMMITTEE ON SCIENCE AND TECHNOLOGY (SUB-COMMITTEE I) WEDNESDAY 22 NOVEMBER 2006
Present Broers, L Platt of Writtle, B Colwyn, L Simon, V Finlay of Llandaff, B Soulsby of Swaffham Prior, L (Chairman) Taverne, L May of Oxford, L
Memorandum by the Department of Health
Introduction 1. The Government welcomes this opportunity to set out its position on allergy and allergic conditions. 2. This memorandum is structured in accordance with the particular questions asked in the Committee’s Call for Evidence. Although this inquiry will not focus primarily on allergy service provision, many of its questions were addressed in the recently completed review of services for allergy (“the DH review”) that was undertaken by the Department of Health (DH) following an inquiry (Report, November 2004) by the House of Commons Health Committee. 3. This memorandum therefore refers to—but does not repeat at length—the evidence presented in the report of the DH review, A review of services for allergy—the epidemiology, demand for and provision of treatment and eVectiveness of clinical interventions, published in July 2006. Members of the Committee have had printed copies of this report. It is available on the DH website, along with supporting information on the epidemiology and on clinical interventions, at: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/ PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT–ID%4137365&chk%/Z3Wtj. 4. The memorandum includes contributions from: — the Health and Safety Executive (HSE) and the Department for Work and Pensions (DWP), covering work-related allergy and Industrial Injuries Disablement Benefit, attached as Annex A; — the Department for Education and Skills (DfES) on allergic diseases and schools—including a summary of medicines guidance to schools, attached as Annex B; and — the Department for Communities and Local Government (DCLG) on housing policy and regulations, attached as Annex C. 5. The key points made in Annex A are that: — work-related allergies have declined over the last 10 years; — HSE is working in partnership with key stakeholders to ensure this downward trend continues; and — there is a robust regulatory framework in place to tackle work-related allergies.
Defining the Problem
What is allergy? 6. Allergy can be defined as a hypersensitivity, a heightened or exaggerated immune response to some external stimulus or stimuli. Allergic processes contribute to a range of conditions—including asthma, rhinitis and eczema—many of which also occur in the absence of a specific allergy. Various allergic conditions often co-exist in the same individual. Also, some individual allergic disorders may cause symptoms in several organ systems simultaneously. 2 allergy: evidence
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7. Allergy is very common. Around a third of the population have some form of allergy at some point in their lives. In England, about three million people each year are seen in primary care with conditions that may be allergic in origin.
What is the difference between allergy and intolerance? 8. Unlike allergy, intolerance (for example, food intolerance) does not involve the immune system. It is generally not life threatening. Around 20 per cent of adults have perceived food intolerance. The correct diagnosis of food intolerance generates a substantial workload for services.
What is and what is not known about the origins and progression of allergic disease? 9. Whilst a good deal is known about the mechanisms of allergic processes, the underlying causes of allergic conditions in individuals and populations are more diYcult to understand. A variety of factors have been identified as possible causes or modifiers of allergic illness. These include genetic factors, early allergen exposure, maternal and infant feeding practices, viral infections, environmental tobacco smoke and other pollutants, pet contact, family size and rural living. 10. Allergies, once established, tend to be lifelong despite treatment, although some forms—such as egg and milk allergy in infants—do frequently resolve.
Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such a high prevalence of allergy? 11. The DH review found good evidence that allergy has increased in the population in the last 30 years. However, for the last 10 years the picture is less clear—some studies suggest that it has not increased, and may even have fallen (for example, the latest ISAAC study data from the UK), whilst others show a continued rise in allergy symptoms. 12. The apparent changes in the prevalence of allergy over the last three decades cannot be reliably explained, and nor can the particularly high prevalence of allergic conditions in the UK and certain other developed countries. A number of theories have been considered, to do with changes in our environment as a consequence of increasing aZuence and modern lifestyles. Possible influences include increased exposure to allergens or pollutants, dietary changes and a change in infectious triggers. 13. In 1995, DH’s Committee on the Medical EVects of Air Pollutants (COMEAP) published a major report on Asthma and Outdoor Air Pollution. It concluded that, with regard to the initiation of asthma (ie causing the disease in the first place), most of the available evidence did not support a causative role for outdoor air pollution. While it was accepted that exposure to air pollutants could produce a worsening of symptoms in those suVering from asthma, factors other than air pollution (diet and the role of infections, for instance) were more likely to have had more of an impact on the number of people suVering from asthma. 14. COMEAP is working on a new report, Does Air Pollution Cause Asthma?, to be published in 2008.
What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 15. From secondary analyses of national databases, the direct cost to the NHS of managing allergic diseases has recently been estimated at over £1 billion per annum in the UK. Primary care prescribing costs are around £0.9 billion per annum, or 11 per cent of the total drugs budget. 16. There is a considerable body of data on the occurrence of allergic conditions in the population, although the distribution of research studies is heavily weighted towards asthma. There is much less information about the extent to which these conditions are caused by untreated allergy in the community, or about the distribution of severity and unmet need for specific services. 17. Furthermore, as the DH review concluded, the absence of baseline data on the profile of services and the cost makes it diYcult to develop a strategic national view of how and where services could be developed. DH will consider what actions may need to be taken to support the NHS and others in developing baseline data on NHS services, capacity and costs, and workforce—including cost modelling, using evidence from a range of services in diVerent settings. allergy: evidence 3
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In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)? 18. The DH review highlighted that the indirect and intangible costs of allergic diseases, such as school or workdays lost, lower productivity or diminished quality of life, are potentially huge. A survey in the late 1990s found that 38 per cent of children and 16 per cent of adults in the UK had lost school/work days due to their asthma in the past year. In 1994–95, it was estimated that 17 million work days were lost due to asthma, costing an estimated £1.1 billion. Studies have also reported the economic burden due to reduced productivity at work caused by allergic rhinitis to be greater than that resulting from the treatment of the condition and its symptoms. 19. Evidence on the socio-economic impact of work-related illness is given in the corresponding section of Annex A. 20. In general, it is not possible to say how many pupils do not attend school or miss exams because they are aVected by allergies, because data on pupil absence is not routinely collected in this level of detail. From September 2006, schools will be asked to inform the Department for Education and Skills (DfES) of the reasons for pupil absence from school. Illness will be one category—but it would overburden schools to have to record for each absent pupil their individual type of illness. 21. Pupils who suVer from allergies may need to have medication whilst at school: a summary of the current guidance is at Annex B.
Treatment and Management
What is the effect of current treatments on the natural history of allergic disease? 22. The DH review report sets out what is known about the nature and the eVectiveness of clinical interventions for allergy, drawing on professional input, including clinical guidelines which have been informed by research. 23. Making an allergy diagnosis is a key step in allergy management. An accurate diagnosis targets the appropriate clinical intervention and allows avoidance of the allergic trigger and amelioration or resolution of symptoms. 24. Allergy treatments in widespread use can be classified in four broad categories—symptom control, allergen avoidance, rescue medication and immunotherapy. Examples are given in the DH review report. New therapies are also in development.
What is the evidence-base for pharmacological and non-pharmacological management strategies? 25. A number of Royal Colleges and professional bodies have drawn up good practice guidelines for specific allergic conditions. However, there are no nationally agreed, evidence based clinical guidelines which address allergic conditions as a whole—nor nationally agreed clinical guidelines or protocols addressing how patients with less serious allergies can be treated in primary care. 26. As early steps to follow its review, DH will consider the options for commissioning the development by the National Institute for Health and Clinical Excellence (NICE) of guidelines for the diagnosis and management of allergic conditions, and work with the Royal Colleges and others on guidance for referral and care pathways. 27. To inform its review, DH commissioned an overview of systematic reviews of the research evidence on clinical interventions for allergy, focusing particularly on service delivery and organisation. This “review of reviews” also identified significant gaps in research knowledge. The full report was published on the DH website with the DH review report itself.
Is the level of UK research into allergy and allergic disease adequate? 28. There is no absolute way of determining whether a level of research spend is adequate. Ultimately, it is a value judgement by a range of research funders with diVering remits. Such judgements will include consideration of disease burden, likely success of scientific endeavour, likely impact on health of aVected population, capacity to address issues relevant to the UK and assessment against other competing priorities. 4 allergy: evidence
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29. In May 2006, the UK Clinical Research Collaboration (UKCRC) published the first ever national analysis of spending on health research in the UK (UK Health Research Analysis). This analysis included most government and charity funding on all types of health research across all areas of health and disease during the year 2004–05. 30. Analysis was done by “high level” categories such as respiratory disease and cardiovascular disease. The UKCRC analysis shows that there appears to be an imbalance in research funding for respiratory disease against burden of disease. The majority of research on allergies has focused on asthma, and therefore probably falls within the respiratory disease category. However, it is not clear that the imbalance in spend against disease burden reflects the position for allergy-related respiratory disease (since much of respiratory disease burden is not allergic in origin); and it obviously provides no indicators about non-respiratory allergic research. 31. The main agency through which the government supports medical and clinical research is the Medical Research Council (MRC). Other research councils—the Biotechnology and Biological Sciences Research Council and the Economic and Social Research Council, for example—also support research of relevance to health and healthcare. The Councils’ umbrella body, Research Councils UK, is submitting a separate memorandum of evidence to the Committee. 32. DH funds research to support policy and the delivery of eVective practice in the NHS through a number of national programmes. It also meets the service costs to the NHS of research funded by the research councils and charities and undertaken in research-active NHS organisations. 33. The new health research strategy, Best Research for Best Health, was launched in January 2006. It set out the Government’s goals for research and development in the NHS and demonstrated DH’s commitment to creating a vibrant research environment that will contribute to the health and wealth of our nation. 34. The key planks of the strategy are to: — establish the NHS as an internationally recognised centre of research excellence; — attract, develop and retain the best research professionals to conduct people-based research; — commission research focused on improving health and care; — strengthen and streamline systems for research management and governance; and — act as sound custodians of public money for public good. 35. Best Research for Best Health has a range of related objectives that require diVerent approaches. We have developed implementation plans for sixteen of the major components for the new National Institute of Health Research (NIHR), through which we shall deliver many of the components of the strategy. Further details are available on the NIHR website (www.nihr.ac.uk), together with details of calls for proposals. 36. Some of the programmes of research being carried out by NHS organisations and that have allergy and allergic disease as a major component are shown in the following table.
NHS R&D External allocation funding NHS organisation Programme 2005–06 (£m) 2005–06 (£m) Guy’s and St Thomas’ NHS Allergy and obstructive lung disease 0.6 2.6 Foundation Trust King’s Consortium Allergy and obstructive lung disease 0.5 0.7 Royal Brompton and Harefield Management of severe respiratory 3.5 3.0 Hospitals NHS Trust disease: atopy, allergy and asthma Southampton University Allergy and inflammation 1.2 1.8 Hospitals NHS Trust South Manchester University Obstructive and parenchymal lung disease 0.6 1.2 Hospitals NHS Trust
37. The DH Policy Research Programme funds a programme of research at the Social Medicine and Health Services Research Unit, now based at Imperial College. Part of this programme focuses on the role of allergy in asthma. In addition, it has funded a £1 million initiative on the impact of air pollution on health, which is now drawing to a close. allergy: evidence 5
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38. Other national programmes (principally the Health Technology Assessment programme) have, over the last five years, allocated some £2.2 million to primary research and systematic reviews concerned with allergy. 39. The Food Standards Agency supports a programme of research on food allergy and intolerance. It is submitting a separate memorandum to the Committee. 40. Research on allergy is also supported through EC Research Framework Programmes. Proposals for the 7th Framework Programme (2007–13) make provision for research relating to allergy and allergic diseases in several areas of the Programme—including under “chronic diseases” within the Health theme, “food, health and wellbeing” within the Food, Agriculture and Biotechnology theme, and “environment and health” within the Environment theme. 41. Funding for research in allergy and allergic disease under the 6th Framework Programme (2002–06) includes 14.4 million euros (£9.7 million) for a Global Allergy and Asthma European Network and 14.1 million euros (£9.5 million) for a UK-led integrated project on the prevalence, cost and basis of food allergy across Europe. 42. The review of systematic reviews commissioned by DH for its review of services for allergy found that much current research deals with specific interventions, but fails to address questions around models and methods of service delivery. It suggested that more work might be required to investigate the role of specialists, and the linkage between specialist and generalist services. Such studies would need to collect basic demographic information. The review also highlighted the need for consistency in the standardisation of key measures in trials. 43. In all, the DH review highlighted a range of gaps in the research evidence—relating to epidemiology, diagnostics and interventions, service models and also basic science. The Department proposes to invite key research funders to note these gaps.
What are the most promising areas of research into preventing or treating allergy? 44. The Government is aware that new therapies are being developed that are aimed at modifying the underlying immunological processes that either cause or mediate clinical allergy. Examples include: — anti-IgE therapy, which is presently licensed in the UK only for severe asthma, but could potentially be used in the management of other severe IgE (immunoglobulin E) mediated allergic problems; — new types of immunotherapy, for example with recombinant allergens or peptides, are in development and clinical trials: for example, peptides have been used in a randomised controlled trial in cat allergy and recombinant allergens are being developed for use in peanut allergy; — sublingual immunotherapy (SLIT) is a safe treatment significantly reducing symptoms and medication requirements in allergic rhinitis; further research is required concentrating on optimising allergen dosage and patient selection; — vaccines are in development for a number of diVerent allergic conditions; and — other research on prevention is in progress, although this approach is not yet clinically validated or adopted in current allergy practice. 45. Extensive research on the mechanisms of allergy and therapeutics to combat allergic disease will provide an opportunity to find new strategies for establishing eVective treatments. Continued research on the molecular mechanisms of allergic disease can be expected to generate new forms of therapy.
Government Policies
How effective have existing Government policy and advice been in addressing the rise in allergies? 46. The DH review identified good practice in the NHS, across the wide range of services available for people with allergies, and the spectrum of skills and competences of clinicians involved in their care. However, it has also revealed some gaps in the knowledge and skills of clinical staV dealing with allergy (especially in diagnosis), in systematic planning and commissioning of services for allergy, in baseline data on NHS services for allergy, relevant service capacity and costs, and workforce, and in research. 6 allergy: evidence
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47. The DH review report acknowledges that, although incomplete, the evidence is suYcient for recommendations to be made for action over the next few years in order to improve services for allergy. It identifies three areas in which initial action will be of key importance: — local commissioners to establish levels of need for services for allergy in their health community; — SHA workforce planners to work with Deans and providers to explore the scope for creating additional training places for allergists; and — DH to consider the options for commissioning the development of NICE guidelines for allergy, and work with the Royal Colleges on guidance for referral and care pathways. 48. The key levers for change for NHS services for allergy in the future will, essentially, continue to be for local rather than national level action. In the light of local priorities, local health commissioners will need to consider—for allergy as for other services—how to include patient choice, high quality information for the public, increased investment in the Expert Patient Programme, practice based commissioning for services, joint commissioning between Primary Care Trusts and local authorities, introducing a wider range of providers, workforce modernisation, better clinical and management information and a focus on self care, in line with the White Paper Our health, our care, our say: a new direction for community services (January 2006). 49. Nevertheless, at national level, the DH review has been a catalyst in energising and bringing together a wide range of national and local interests in constructive debate on the future of services for allergy. The Government is committed to sustaining and building on that momentum. 50. The DH review report stresses that, in the context of current constraints in the NHS and the Department, any initiatives to support the NHS and others to generate and lever change in services for allergy will need to be incremental, phased in steps over a number of years. It will be essential for stakeholders—including patients, the NHS, Royal Colleges, the independent sector and voluntary organisations—to work together if this is to be achieved.
How is current knowledge about the causes and management of allergic disease shared within Government? For example: — Do housing policy and regulations governing the indoor environment pay enough attention to allergy? 51. A contribution from the Department for Communities and Local Government (DCLG) addressing this question is attached at Annex C. — How eVectively are food policy and food labelling regulations responding to the rise in food allergies? 52. The separate memorandum to the Committee from the Food Standards Agency will cover food policy and labelling. 53. The Committee may also wish to know that the Government has an air pollution information service, the “Air Quality Bulletin”, which provides free up-to-date information and forecasts on air quality in areas throughout the UK. It informs the public when pollution levels are high and advises accordingly. 54. The Department for Environment, Food and Rural AVairs (Defra) has published a leaflet, in partnership with DH, the Scottish Executive and the Department of Environment in Northern Ireland, entitled Air Pollution: what it means for your health; the public information service. It explains where to get up-to-date information on current levels of air pollution, what air pollution can mean for your health, and what you can do about it.
Patient and Consumer Issues
What impact do allergies have on the quality of life of those experiencing allergic disease and their families? 55. The DH review was informed by people with—and parents of children with—allergic conditions, both through individuals as members of the National Allergy Advisory Group or attending the stakeholder workshops, and through evidence submitted by patient representative organisations. allergy: evidence 7
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56. As the Parliamentary Under Secretary of State acknowledges in his foreword to the DH review report, “those living with severe allergy can face a huge battle every day, and their quality of life and that of their extended family may be greatly aVected. In surveys, many people express feelings of constant stress and anxiety. Everyday areas of life may be aVected, such as eating out as a family, school trips, schools meals and packed lunches, children’s parties and other social situations.” 57. The evidence is that people with allergies often feel let down by a poor and frequently unobtainable service. For those living with allergy severe enough to require specialist care, the lack of allergy services is a problem which can greatly aVect their quality of life.
What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers?
58. With high quality information and guidance, those aVected by allergy can be empowered to manage the condition and protect themselves from harm, generally by learning to self-administer appropriate medication or to avoid those allergens which cause an allergic reaction. The DH review recognises the help that not-for-profit organisations give, through helplines and other information services, to fulfil an important need that is yet to be addressed by the NHS. DH has helped support these eVorts through grants made under Section 64 of the Health and Public Services Act 1968. 59. The DH review highlighted the importance of general practitioners and others in primary care having suYcient clinical knowledge and support systems in order to spot allergy in the early stages, so that an eVective management plan can be oVered from the start, and patients are not referred unnecessarily to specialists for care of less severe allergic disease.
Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory?
60. Private and voluntary healthcare providers are subject to regulation by the Healthcare Commission if they provide services set out in current legislation. Those services do not include over the counter allergy tests. However, providers registered with the Commission might oVer allergy tests as part of a wider range of services. 61. DH will be consulting later in the year on the range of services, including diagnostic techniques, to be subject to regulation by the Healthcare Commission. There are no plans to extend the scope of regulation specifically to include over the counter allergy tests. 62. Allergy test kits can be regulated as either medicines or medical devices, depending on how they work. Those that place something on or under the skin to provoke a reaction act immunologically, and are regulated as medicinal products. There are currently no such test kits available over the counter in the UK. There are, however, products available on prescription and these tests are usually carried out in specialist clinics. 63. The safety, quality and performance of those tests which detect antibodies from blood or other human fluid samples in vitro are regulated under the Medical Devices Regulations 2002. Those in vitro diagnostic devices (IVD) intended to be supplied direct to the public have the self test element assessed by a third party certification organisation, known as a notified body, which has been designated by an EC member state on the basis of strict expertise criteria. Moreover, the instructions for use that the manufacturer is required to supply would be expected to warn of possible false results, and provide guidance on interpretation and that, if symptoms persist, the user should seek medical advice. 64. UK manufacturers of IVDs have to register with the Medicines and Healthcare products Regulatory Agency (MHRA). The Agency believes the current regulatory regime is appropriate to control those over the counter allergy test kits that are devices. 65. Other over the counter allergy tests, employing such techniques as hair analysis and electromagnetic field detection, which are not for a medical diagnostic purpose do not come within the scope of the Medical Devices Regulations. They would, however, be regulated as consumer products under the General Product Safety Regulations, which are enforced by local authority Trading Standards Departments. 8 allergy: evidence
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Annex A
Work-related aspects—contribution from the Health and Safety Executive and the Department for Work and Pensions Introduction 1. The tripartite Health and Safety Commission (HSC) has overall responsibility for policy on health and safety, and advises Ministers on relevant standards and regulations. The Chair and members of the Commission are appointed by the Secretary of State for Work and Pensions following consultation, advertisement and open competition. The Health and Safety Executive (HSE) advises and assists HSC and has a statutory responsibility to make adequate arrangements for the enforcement of the Health and Safety at Work Etc Act 1974 and other relevant statutory provisions in Great Britain.
Defining the Problem
What is allergy? What is the difference between allergy and intolerance? 2. Chemicals and biological agents used in or arising from work activities can cause the same allergic diseases, and by the same mechanisms, as those in the more general environment. The most commonly reported work-related allergic respiratory disease is occupational asthma, though rhinitis and extrinsic allergic alveolitis (EAA) are also important. By far the most common type of work-related skin allergy is allergic contact dermatitis. Anaphylaxis is a rare consequence of some workplace exposures. 3. High levels of substances irritant to the lung can cause persisting asthma and exposures to low levels of irritants at work can exacerbate pre-existing asthma, but these are not allergic reactions. Exposure to beryllium arising from work activities may cause a rare, specific and atypical allergic disease of the lungs called berylliosis.
What is and what is not known about the origins and progression of allergic disease? 4. Occupational asthma, rhinitis, EAA and occupational skin allergy arise because of abnormal sensitivity of the human immune system to specific substances. High molecular weight substances, such as laboratory animal proteins, enzymes in detergents or mouldy hay, may provoke the response directly. Low molecular weight substances, such as isocyanates probably combine with proteins in the body, and provoke the allergic reaction by altering human protein structure. Little is known about the relative contributions of diVerent routes of exposure (ingestion, inhalation and/or penetration through the skin) to the development of allergy. 5. The main causes of occupational asthma are reviewed in HSE’s publication Asthmagens? Critical Assessments of the evidence for agents implicated in occupational asthma (http://www.hse.gov.uk/asthma/asthmagen.pdf). Lists of substances that commonly cause occupational asthma and rhinitis are included in the Regulations of the Industrial Injuries Scheme (http://www.iiac.org.uk/prescribed diseases/index.asp). 6. Within groups of people exposed to respiratory allergens: — some will show no evidence of an allergic reaction; — some will show evidence in immunological tests of some immune reaction—they will be “sensitised”—but not have any symptoms; — some will be sensitised and have symptoms; and — some may have symptoms without objective evidence of sensitisation in immunological tests. 7. It is easier to demonstrate sensitisation to high molecular weight substances by laboratory tests than to those of low molecular weight. 8. Three general determinants have been identified for an increased risk of occupational asthma, and are likely to be relevant to rhinitis too. They are: atopy (in the case of high molecular weight allergens); smoking (low molecular weight allergens); and a particular genotype. There is good evidence that the risk of developing occupational asthma is directly related to the levels of exposure in the workplace, although there is insuYcient data to define a level at which there is no risk. It is generally thought that clinical allergic reactions can be induced in sensitised individuals by much lower exposures than are required to initiate disease. allergy: evidence 9
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9. EAA is most often due to a work exposure. It is not associated with atopy, and less readily associated with specific genotypes. Smoking appears to reduce the risk. 10. Little is known about individual susceptibility to the development of skin allergy, except that allergic skin conditions (along with other allergic conditions such as asthma and hay fever) may run in families. A family history of asthma, hay fever or eczema (skin allergy) may predispose to childhood eczema—this is known as atopic dermatitis. An individual with atopic dermatitis may be more prone to skin allergy and skin irritation in later life. 11. Specific respiratory allergies persist once they have become established. There is evidence that longer exposure to occupational respiratory allergens, and the presence of more severe disease, before diagnosis is associated with a poorer prognosis (eg persisting symptoms after cessation of further exposure to the allergen in the case of asthma, development of irreversible fibrosis—scarring—of the lung in the case of EAA). Complete prevention of exposure to the causative agent does not necessarily lead to complete remission of symptoms, but improvement can continue over years afterwards. Where aVected individuals reduce, but do not eliminate, further exposure they are more likely to have persisting symptoms, and worsening asthma over the longer term. 12. There is very little published information on clinical outcome in cases of workers who develop skin allergy related to exposures at work. HSE is jointly funding, with the British Occupational Health Research Foundation (BOHRF), a research project to identify prognostic factors for people diagnosed with work- related contact dermatitis. However, in general, once work-related skin allergy has developed, avoidance of exposure is necessary to control progression of the disease and prevent the reoccurrence of symptoms. 13. HSE’s approach, through the appropriate regulatory framework, is to prevent individuals from developing occupational allergic diseases by ensuring that employers use, where possible, a safer alternative or, if this is not possible, that workplace exposures are adequately controlled. Health surveillance in the workplace is also important so that early signs of allergic diseases can be identified and exposures controlled.
Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such high prevalence of allergy? 14. Although the overall burden of occupational asthma and work-related allergic contact dermatitis in the UK is not known, a number of sources provide information on the possible scale and probable trends in the diseases. 15. The latest Survey of Self-reported Work-related Illness estimated that: — 137,000 people who had ever worked in 2004–05 had “breathing or lung problems” caused or made worse by work; and — 29,000 people who had ever worked in 2004–05 had “skin problems” caused or made worse by work. 16. Although these figures give an indication of the number of people currently suVering from occupational lung and skin problems (the disease prevalence), it is diYcult to estimate what proportion are suVering from asthma or allergic contact dermatitis. Estimates of the proportion of asthma cases that are work- related from other studies (the challenge is to identify cases that are primarily due to work activities in any common disease having both work and non-work-related causes) vary between 2 per cent and 15 per cent. 17. An indication of the number of new cases of occupational asthma and contact dermatitis (including allergic contact dermatitis) occurring each year (the disease incidence) can be obtained from the reports of cases from physicians who participate in the respective voluntary surveillance schemes forming part of The Health and Occupation Reporting network (THOR). According to these figures, over the last three years (2003–05): — there were around 570 new cases of occupational asthma per year, compared with about 1,000 new cases per year during the mid 1990s; and — there were around 2,400 new cases of work-related contact dermatitis per year, compared with 3,000–4,000 new cases per year during the late 1990s. 18. These figures tend to underestimate the true incidence, since many cases will not be referred to a consultant physician, and not all workers have access to occupational physicians. Whilst trends can also be misleading, because of year-by-year variability caused by changes in the numbers of participating 10 allergy: evidence
22 November 2006 doctors and alterations in their caseloads, more detailed analyses suggest that there is likely to have been a real reduction in the incidence of both diseases. Further statistical information is available at: http://www.hse.gov.uk/statistics/. 19. Prevalence and incidence statistics are available from other countries but the comparison of national rates is problematic, because of diVerences in the data collection procedures and systems of notification. No firm conclusions can, therefore, be drawn from international comparisons about whether or not the prevalence of work-related allergy in the UK is higher than that in other countries.
What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 20. There is currently no simple test for objectively confirming cases of work-related allergic respiratory disease. Diagnosis depends on expert clinical judgement in the great majority of cases. Standardised criteria for diagnosis and for accepting an occupational origin would significantly assist with measuring the trends in the incidence of these diseases. 21. An HSE funded investigation of patient referrals from primary to secondary care found that there were some significant delays before patients were being referred to secondary care and subsequently diagnosed. A baseline audit of hospital medical care provision for diagnosis of occupational lung disease, undertaken for HSE and the British Thoracic Society, illustrated a wide variation in the facilities available in respiratory departments and clinical approaches employed by general respiratory consultants for treatment of occupational asthma. It found that it was usual for patients to be diagnosed in-house, as opposed to being referred to a specialist occupational respiratory centre, but that respiratory departments often lacked the necessary resources to arrive at a definitive diagnosis. 22. A Group of Occupational Respiratory Disease Specialists (GORDS), convened regularly by HSE, aims to develop a standard of care document for the diagnosis of occupational asthma, that will be ratified by the relevant medical bodies. This will reiterate key messages from other work, highlighting diagnosis and management issues and will be promulgated throughout the medical community, including general respiratory consultants, general practitioners, occupational health consultants and other occupational health professionals. 23. The wide variation in disease severity is likely to be a key issue –particularly for skin disease—since many less serious cases may not be recognised by individuals or by physicians. Thus, the THOR schemes are subject to under-reporting since specialist physicians only tend to see the more serious cases, and those with more minor symptoms may not seek medical attention anyway. In addition, many workers do not have access to occupational physicians. The Self Reported Work Related Illness Surveys rely on individuals” own perceptions of the problem and there may be a tendency for people to misinterpret the relevance of their work exposures to their symptoms. 24. DiYculties in attribution of cases to workplace causes are likely to aVect both these sources. Comprehensive epidemiological assessment of work-related allergic disease is impractical because of, for example, the wide range of occupational allergens and the circumstances in which they are used. In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)? 25. In the 2004–05 Survey of Self-reported Work-related Illness (SWI), an estimated 791,000 full time equivalent working days were lost due to breathing or lung problems in 2004–05 (95 per cent CI: 387,000–1,194,000), a substantial proportion of which may be due to occupational asthma, with an average of 18.6 days lost per case (95 per cent CI: 9.9-27.3). This compares with 28.4 million days lost due to all self-reported work-related illness in the same year, with an average of 23.1 days lost per case. 26. In the 2001–02 SWI (the most recent year in which there were suYcient sample cases to produce a reliable estimate of the number of working days lost due to skin problems), it was estimated that 230,000 (95 per cent CI: 96,000-370,000) working days were lost due to skin problems, with an average of 8.2 days lost per case (95 per cent CI: 3.9–12.5). The total number of days lost due to all self-reported work-related disease in 2001–02 was about 32 million days with an average of 23 days lost per case. 27. Research recently published by HSE on The True Costs of Occupational Asthma in Great Britain (http://www.hse.gov.uk/research/rrhtm/rr474.htm found that the cost burden of new cases falls most heavily on the individual worker and society (taxpayers or Government). The report estimates total lifetime costs allergy: evidence 11
22 November 2006 to society of new cases diagnosed in 2003 ranging from £71.7 to £100.1 million. If comparable numbers of new cases were diagnosed in future years, this would give rise to additional streams of lifetime costs of similar magnitude. Treatment and Management
What is the effect of current treatments on the natural history of allergic disease? 28. Treatments for occupational allergic disease are identical to those for non-occupational allergic disease. HSE is not involved in the treatment of individual suVerers. Our focus is on preventing ill health by ensuring that the legislative framework means that employers prevent or, if this is not possible, adequately control exposures to substances known to cause work-related allergic disease, and that health surveillance is in place to identify signs of disease as soon as possible.
What is the evidence-base for pharmacological and non-pharmacological management strategies? 29. Within the occupational setting, the most eVective strategy is removal of the allergic individual from exposure to the substance causing the allergy.
Is the level of UK research into allergy and allergic disease adequate, and what are the most promising areas of research into preventing or treating allergy? 30. Much valuable research has already been conducted by HSE on substances causing asthma in the workplace. There are areas that could be explored in further detail (primary causes, individual susceptibility, prognosis and mechanisms). HSE is now aware of the main causes of allergic disease and how exposures can be controlled. Therefore, our emphasis is now on achieving the behaviour change in the workplace so that employers and employees understand the need for, and use, suitable control measures.
Government Policies
How effective have existing Government policy and advice been in addressing the rise in allergies? 31. Evidence suggests that there is a downward trend in the incidence of work-related allergies. We do not have information at this stage on how HSE policy and advice has contributed to this trend, although a planned programme of evaluation will address this over the next two years. 32. Nevertheless, occupational asthma and allergic contact dermititis continue to be priorities for HSE within its Disease Reduction Programme; the aim is a 10 per cent reduction in the incidence of these diseases by 2008 from a 2004 baseline. HSE also has a target to reduce the incidence of occupational asthma by 30 per cent by 2010 compared with the 2000 baseline.
How is current knowledge about the causes and management of allergic disease shared within Government? 33. In 2001, the Health and Safety Commission agreed a package of measures aimed at achieving the 2010 target. An Asthma Project Board was set up, because partnerships with stakeholders are vital if this target is to be reached. Its members include representatives from unions, industry, an asthma charity and health professionals. The board provides mechanisms to ensure that information is shared with organisations who have an interest in occupational asthma. 34. As a result of partnership working, Asthma UK has developed a Workplace Charter that sets out 10 steps to reduce the impact of asthma in the workplace (http://www.asthma.org.uk/all about asthma/asthma at work/workplace.html), and the British Occupational Health Research Foundation has published an evidence based review and guidelines on the identification, management and prevention of occupational asthma. These are aimed at doctors and nurses in general practice, occupational health and respiratory medicine and at employers, safety representatives and workers who might be exposed to occupational asthmagens (http://www.bohrf.org.uk/downloads/asthevre.pdf). 35. GORDS allows for a dialogue between clinicians who see cases of respiratory allergy and HSE. It provides an opportunity for the early identification of any new workplace allergens. 12 allergy: evidence
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36. The THOR scheme for reporting work-related respiratory and skin disease also presents a mechanism for the identification of new allergens, and provides a useful recurring reminder to NHS physicians of the need to consider the possible work-relatedness of allergic respiratory and skin disease. 37. Clinicians and others can also seek advice about specific incidents of allergic disease from HSE’s experts, including doctors, inspectors and hygienists. HSE works in partnership with the Local Authorities and is making scientific resource available to tackle occupational asthma and dermatitis in premises for which they are responsible (eg bakeries and hairdressers). 38. The HSC’s Advisory Committee on Toxic Substances and various Industry Advisory Committees also provide a route for working with key stakeholders in specific areas. Coordination and information sharing across administrations, departments and agencies dealing with risks from chemicals is well developed, and HSE plays a full part in this. The Government carries out a significant amount of monitoring for chemicals in the environment, in food and in biota. Much of the monitoring currently carried out is in response to legislative requirements, which increasingly is driven by Europe. 39. In its February 1999 report, an interdepartmental working group, chaired by HSE and constituted to review the arrangements in place across Government for monitoring the ill-health eVects of pesticide exposure, noted the well-recognised diYculty in determining a causal link between chronic ill-health symptoms and exposure to hazardous substances such as pesticides. There is little evidence to suggest that pesticides are a significant contributory factor in incidences of allergy, other than a small number of cases of alleged multiple chemical sensitivity following exposure to, for example, pesticide spray drift. In the light of the known diYculty set out above, the working group recommended the continued use of studies to investigate alleged links between chronic ill health and pesticide exposure. The Government’s response to the Royal Commission on Environmental Pollution report Crop Spraying and the Health of Residents and Bystanders is at www.defra.gov.uk/environment/rcep/pdf/rcepcropspray-response.pdf.
Patient and Consumer Issues
What impact do allergies have on the quality of life of those experiencing allergic disease and their families? 40. Both occupational asthma and dermatitis can interfere with normal life and cause significant disability. It is generally accepted that a diagnosis of work-related allergic disease is often associated with economic disadvantage for the aVected person, either because of the impact of the illness itself on sickness absence, ability to maintain employment or the need for job change to avoid further exposure. Individuals diagnosed with occupational asthma or severe dermititis can suVer financial and employment consequences as a consequence of having to move to a lower paid job, or leave the labour force, in order to avoid exposure. The diseases may significantly aVect all aspects of life, particularly if the work-related allergen is a substance that is ubiquitous in the domestic situation—eg allergy to a fragrance present in cosmetic products, cleaning products, food protein. 41. For those with chronic symptoms and a minimum degree of disability, no-fault compensation is available in the form of state-funded Industrial Injuries Disablement Benefit (IIDB). IIDB provides compensation for disablement due to an industrial accident or prescribed disease. It is paid according to the degree of disablement and takes no account of factors other than the physical or mental condition of the injured person. It can be paid whether or not the person is working and is not taxable. 42. A number of prescribed diseases are allergic responses to substances encountered at work. They are: — extrinsic allergic alveolitis (EAA), including farmer’s lung; — anaphylaxis; — allergic rhinitis; — non-infective dermatitis: and — occupational asthma. 43. The Secretary of State for the Department for Work and Pensions (DWP) is advised which diseases should be prescribed by the Industrial Injuries Advisory Council (IIAC). It is a statutory function of IIAC to review all aspects of the current IIDB scheme. The Secretary of State will normally implement IIAC recommendations. For example, following an incident of occupational asthma at a major car manufacturer in the UK, IIAC have recently published a report recommending that the current legislative description of EAA be broadened to include exposure to the mists of metal working fluids. The Secretary of State has accepted the report and is considering its recommendations. allergy: evidence 13
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What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? 44. HSE is involved in a wide range of interventions in specific industries, to raise awareness of health risks amongst employers and employees and to provide information about how to control exposures in the workplace. We consider during the planning process the most eVective way of communicating with individual groups, whether through a leaflet, detailed guidance, a website, interactive seminars or an inspector visit. 45. The Chemicals (Hazard Information and Packaging for Supply) Regulations 2002 require the supplier of a dangerous chemical to identify the hazards of the chemical, give information about the hazards to their customers and package the chemical safely. In some cases, from HSE’s perspective, the information provided could be improved and we are working with suppliers to achieve this. 46. More emphasis could be placed within occupational training provision on causes of allergy and its prevention. This would be particularly relevant for those occupations where the risk of allergy is highest. Improvements could also be achieved through better training for primary care physicians on early recognition and diagnosis of work-related allergy. HSE is currently funding research to develop training for practice nurses on the symptoms and causes of occupational asthma, to empower them to give advice and guidance to patients as well as to reduce the time it takes to diagnose cases of occupational asthma.
Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory? 47. The health and safety legislative framework is robust and comprehensive. Under the Control of Substances Hazardous to Health 2002 (as amended) Regulations (COSHH)—and an accompanying Approved Code of Practice for the control of substances that cause occupational asthma—employers are required to ensure that exposure to substances which may cause asthma or dermatitis is prevented or adequately controlled. COSHH also requires that all employees exposed, or liable to be exposed, to a substance that may cause occupational asthma or severe dermatitis should be under suitable health surveillance. 48. Some specific legislation has been introduced to address particularly significant workplace skin allergens—for example, marketing and use restrictions on the presence of chromium (VI) in cement were introduced in 2005. Experience from other countries demonstrates that this restriction will have a very significant impact on the incidence of chromium-related skin allergy in workers exposed to cement. 49. A key diVerence between work-related allergic diseases and the generality of these conditions is that it should be easier to control exposure, and monitor the eVectiveness of preventive measures, within the context of specific health and safety legislation. 50. Changes to the COSHH regulations in April 2005 placed an explicit emphasis on the need to follow good practice to control exposure. HSE is currently making considerable eVorts to enhance the eVectiveness of these regulations by raising awareness, and providing free industry and task-specific COSHH guidance sheets tailored to a wide range of businesses and employees.
Annex B Summary of Department for Education and Skills/Department of Health medicines guidance to schools 1. In March 2005, DfES and DH issued joint guidance, Managing medicines in schools and early years settings. This document updates, and extends to early years settings, 1996 DfEE/DH guidance on supporting pupils with medical needs in school. 2. The DfES/DH joint guidance sets out a clear framework within which local authorities, local health trusts, schools and early years settings can work together to develop policies to ensure that children requiring medicines receive appropriate support. It explains the roles and responsibilities of employers, parents and carers, governing bodies and management groups, head teachers and heads of settings, teachers and other staV, and of local health services. It considers staYng issues including employment of staV, insurance and training. 3. Other issues covered in the document include drawing up a health care plan for a pupil, confidentiality, record keeping, the storage, access and disposal of medicines, home to school transport, and on-site and oV-site activities. It also contains a set of forms which can be photocopied by users. 14 allergy: evidence
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4. The guidance takes account of the recommendations from the National Service Framework for Children (2004) to ensure safe practice in the management of medicines for children, the new duties on local education authorities, schools and early years settings under the Disability Discrimination Act, and latest medical advice. 5. Chapter 5 of the guidance provides brief information and guidance on anaphylaxis, including food triggers. A child’s health care plan should include information on: — anaphylaxis—what should trigger it; — what to do in an emergency; — prescribed medicine; — food management; and — precautionary measures.
Annex C
Housing policy and regulations—contribution from the Department for Communities and Local Government
Do housing policy and regulations governing the indoor environment pay enough attention to allergy?
Introduction 1. The Department for Communities and Local Government (DCLG) is responsible for two housing policy areas that have a bearing on the prevention of allergies: Building Regulations and the Housing Health and Safety Rating System, which relate to new and existing buildings respectively.
Building Regulations 2. The Building Regulations are intended mainly for the following purposes: — to protect the health and safety of people in and about buildings; — to provide access to buildings for people with disabilities; and — to conserve energy and water. 3. Apart from a few exceptions, the Building Regulations are applied uniformly and do not have diVerent provisions for the needs of diVerent building occupants. Building owners are free to add their own special requirements.
Part F—Ventilation 4. The part of the Building Regulations most relevant to allergies is Part F—Ventilation. The legal requirement of Part F is set out in Schedule 1 of the Building Regulations (2000), and is: There shall be adequate means of ventilation provided for people in the building. We interpret the requirement to mean that the ventilation system should be able to provide suYcient fresh air to maintain reasonable indoor air quality. This assumes the outdoor air is of reasonable quality.
2006 Revision of Approved Document F 5. Ventilation has a significant energy cost, so there is pressure to reduce ventilation rates to the minimum without jeopardising health. Technical guidance on ventilation to support the legal requirement of Part F is given in Approved Document F. This has just been revised to complement guidance on energy saving in the Approved Documents that support Part L—Conservation of fuel and power. 6. For dwellings, Approved Document F recommends the ventilation rate to be between about 0.5 and one air changes per hour. This is considered to be suYcient to control typical levels of the following: moisture (to prevent mould growth), nitrogen dioxide, carbon monoxide, total volatile organic compounds and bio-eZuents. As there are probably hundreds (or thousands) of chemical compounds in indoor air, it is not easy to identify the main ones that adversely eVect health. allergy: evidence 15
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7. The Approved Document F provisions are intended to limit relative humidity in dwellings to below 70 per cent, as current opinion is that this is suYcient to prevent mould growth and associated allergens. If the relative humidity is low enough (eg below 50 per cent), it could slow the development of dust mites (dust mite faeces are associated with triggering asthma attacks). 8. In order to inform the revision of Approved Document F, we have recently sponsored research at University College London (UCL) on the eVect of ventilation rate on dust mite and mould growth. This was mainly a desk exercise but included some computer modelling. An extract from the executive summary of the final report is below: (d) Of particular interest to this project, it appears that most existing data are inadequate for conclusions to be drawn regarding the direct association between ventilation rates and respiratory problems. It is noted that there are many real diYculties in attempting to establish such a relationship. 9. We have also contributed to research by Gaia Architects to develop guidance on AVordable Low Allergy Housing. The current research programme includes: — work at UCL to refine understanding of the hygrothermal conditions (ie pertaining to heat and humidity) in real homes needed to prevent mould growth—which will consider transient as well as steady state moisture levels; and — a feasibility study of introducing a scheme for labelling construction products according to Volatile Organic Compounds (VOC) emissions. There is already a voluntary scheme for paint. 10. The Building Regulations apply to England and Wales. Scotland and Northern Ireland have their own systems, which have broadly similar technical requirements.
Housing Health and Safety Rating System (HHSRS) 11. As stated above, Building Regulations apply mainly to new buildings. Existing housing is covered by the Housing Health and Safety Rating System, which has replaced the housing fitness standard. HHSRS was introduced in England in April and in Wales in June 2006. It brings a prescribed list of 29 health and safety hazards into consideration for compliance with the Decent Home standard and also as a basis for statutory enforcement in the private sector. 12. One of the hazards covered by the system is “damp and mould growth”, and the statutory guidance to local authorities notes that mould spores can trigger allergic reactions, especially asthma. Another is “volatile organic compounds”, some of which are noted in the guidance as potentially causing allergic reactions, especially in people with asthma. 13. The HHSRS is based upon data from the Home Accident Surveillance System, the Home Accident Death Database and the English House Condition Survey. Some hazards (including excess cold, exposure to radiation and falling on stairs) are flagged as particularly relevant to older people, while others (including damp and mould growth, lead ingestion and electrical hazards) particularly the young. 14. The HHSRS regulations and supporting statutory guidance do not dictate the action that local authorities should take in response to particular situations. They provide support for local authority oYcers’ professional judgement. The guidance would assist a local authority in considering how to deal, for instance, with damp in a dwelling occupied by an asthmatic person. In such a case, the authority might require a landlord to take more comprehensive or urgent action than it would require in a case involving an able- bodied and less susceptible occupier.
Conclusion 15. Through the Building Regulations and the HHSRS, current housing legislation brings into the mainstream a number of health and safety issues, including cold, exposure to radiation and features in a dwelling giving rise to fall hazards, that were neglected by the old fitness provisions. As it covers existing homes, Government regards the HHSRS in particular as a significant step forward, moving the emphasis from the condition of the fabric of a dwelling to the impact of any defects on health and safety. 16. Whilst the new system does not address allergies specifically, it does provide local authorities with more of the kind of guidance they need in order to make informed decisions for the benefit of people’s health. Statutory guidance recognises that people with certain pre-existing conditions, such as asthma, may be more susceptible to certain hazards than the population at large. 16 allergy: evidence
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17. Extending control provisions beyond those in Building Regulations or HHSRS guidance would be likely to have significant cost implications for local authorities and the house building industry. Subject to the Committee’s recommendations, this would need more detailed consideration. 18. There is a need for more research on the connection between health and indoor air quality, and we have made a start on this as stated above (paragraphs 8 and 9). In this context, we are committed to keeping the evidence base and guidance under review, and also to an evaluation of the impact of the new system— but it will take time for local authorities and landlords to come to terms with it and for its health and safety impacts to be quantified.
Examination of Witnesses Witnesses: Professor Martin Marshall, Deputy Chief Medical Officer and Director General, Healthcare Quality Directorate, Professor Sally Davies, Director General, Research & Development, Dr Keith Ridge, Chief Pharmaceutical Officer, and Mr Alan Bell, Project Lead, Allergy Services Review, Department of Health, examined.
Q1 Chairman: Thank you for coming. Can I formal level, at memoranda level, the Department of welcome our witnesses today. This is the first Health has worked very closely with Defra on air evidence session of the Select Committee inquiry into pollution and the impact that might have on allergies. allergy. This is a public hearing and it will be webcast. The second example would be our very close working There is an information note available to the public with DfES on developing guidance for medication which states the declared interests of all Members, so for school children, particularly around treatment of we will not be declaring our interests each time. I just anaphylaxis. So we regard collaboration as very wonder if you would like to go along the row, please, important, and I think it is fair to say that the process and introduce yourself to the Committee, and then that we have been through in developing this review we will go through the questions. We have quite a lot has highlighted the importance of collaboration for of questions for you within the hour that we were all of us. planning on, so it would be helpful if you kept your answers concise, if possible, so we can get through Q3 Chairman: Who leads on those meetings? them. We can always return to things if time allows. Professor Marshall: Whoever is relevant to the Professor Marshall: Good morning. My name is particular area, usually at policy oYcial level, for Martin Marshall, I am the Deputy Chief Medical example, Alan’s level. OYcer and I am heading up the team. Mr Bell: Good morning. I am Alan Bell, and I led the recent review of allergy services by the Department Q4 Chairman: Just picking up on what you said of Health. about atmospheric pollution, if there is a conflict of Professor Davies: Sally Davies, Director General, interest between departments I wonder if you could Research, for the Department of Health and the give us an example of how it might be handled, such NHS. as things like airtightness of buildings; when energy Dr Ridge: Good morning. I am Keith Ridge; I am the conservation would suggest that the building should Chief Pharmaceutical OYcer at the Department. be as airtight as possible but that might be detrimental to allergy suVerers. Professor Marshall: Q2 Chairman: I wonder if I could start oV by asking I do not have any personal you how the diVerent government departments specific experience of any conflicts of interest communicate with each other on allergy issues, happening, but in an example of the sort you have including issues around education and training. given what I would expect is close collaboration and Indeed, when was the last time they did? negotiation between the two areas and then trying to Professor Marshall: Perhaps I could take that find common ground. question, thank you. We clearly see collaboration between government departments as very important, Q5 Chairman: My next question is probably for particularly in an area like allergies where there are others at the table. We do have the highest prevalence very clear interests from departments other than the of asthma and allergy suVerers in the world, and I Department of Health. We relate to each other in a wondered what explanation the Department has for number of diVerent ways, some of which are formal, this phenomenon. Perhaps you would like to take it? through standing committees, some of which involve Professor Marshall: Yes, if you do not mind. I am sure joint memoranda and some of which involve the others will have an opportunity to answer some informal working at the policy oYcials’ level. If I other specific questions in their areas. I am sorry, could just give a couple of examples: in terms of a could you repeat the main gist of the question? allergy: evidence 17
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell
Q6 Chairman: We wondered how you could explain was introduce an allergy National Code. I have to say why the UK has such a high prevalence of asthma that that introduction has not been entirely successful and other allergic conditions. and I do not think we have seen particularly better Professor Marshall: It is very diYcult to know how the quality data as a result of it because people are still prevalence of allergy conditions in the UK compares classifying within disease-specific areas. We are with other countries. We think it is high. We also hoping that the introduction of Connecting for think it is high in countries like Australia, New Health, and particularly the introduction of a new Zealand and Canada as well. The problem is having nomenclature system called SNOMED, will help us good quality comparative data. I think we need to to then classify the allergy in a much more specific accept that the prevalence is high in the UK, but how way, actually in a semi-automated way, when high it is relevant to others we do not know. The exact clinicians enter data on to patient records. causes of the high prevalence, again, are unclear; there is not good evidence in this area. So whilst the Q9 Chairman: Would that classification separate scientific evidence is very good at talking about the out allergic from non-allergic, so that as there is a underlying mechanisms causing allergy, the actual classification you will be able to capture better those aetiology—the causes of it—are less clear. There are which are thought to be allergic versus non-allergic a number of diVerent hypotheses; some of them relate causes? to environmental factors like pollutants and Professor Marshall: At the moment it does not, but I smoking, some are related to genetic factors and think it would be desirable if it did. The problem, of infective factors, but probably the most popular course, is that allergy is not a label that hangs over a theory relates to the hygiene hypothesis that suggests patient when they are first seen. So it would have to that, particularly, children are not exposed to the dirt require entry into patient records at a later stage and specific allergens that they might have been when the allergic component becomes clear. exposed to in the past, and therefore their immune system is not primed to deal with them appropriately. Q10 Lord Colwyn: Does the Department make any assessment of the, I would have thought, hundreds of Q7 Lord Taverne: Other countries have high thousands of patients, who never actually get to see a standards of hygiene, many other countries smoke doctor, a specialist or anybody, but who treat more than we do, so it does not explain why we themselves? should have a higher incidence than others. Professor Marshall: The Department of Health itself Professor Marshall: You are right, although I come has not. We are very aware that there are potentially back to my original answer that we do not know a huge number of people with allergies out there who whether we have a higher incidence than others, but come nowhere close to formal health services. The you are right absolutely that we cannot explain the extent to which that matters is unclear, from the high incidence. Certainly the incidence seems to be epidemiological data that is there at the moment. All increasing over the last 30 years, although there is of us will know of people who have allergies who self- some evidence over the last 10 years that some treat, perhaps who go to pharmacies, who actually do specific allergies, specifically asthma, might actually not want to get even close to the formal health be reducing in prevalence now. services in order to treat them, so we do not know how important that is. Q8 Chairman: The Department of Health review on services for allergies, commented that there is a lack Q11 Lord Broers: The Government evidence notes of information on the extent of untreated allergic that the Department of Health’s A review of services conditions. I wonder what you can tell us about what for allergy “identified good practice in the NHS, the Department is doing to improve on its data and, across the wide range of services available for people in fact, have appropriate data collection to know with allergies” but also acknowledged many “gaps” about distribution of severity and unmet need. in the skills of clinical staV, planning of services, Professor Marshall: There are very real problems with baseline data and research. Are these two statements the quality of data in this area and, indeed, in some contradictory? other areas as well. We are doing a number of things Professor Marshall: Perhaps I could ask my colleague, to try to improve it, but the principal problem, I Mr Bell, to answer that question. think, is that some allergies are treated in other Mr Bell: On the face of it they may look organic-specific areas. So, for example, data about contradictory, but I do not think they are. I think asthma are more likely to be found in respiratory what the review showed is that allergy services are areas, or data about eczema are more likely to be provided in diVerent ways around the country by a found in dermatological areas than it is classified range of clinical staV. There are examples of excellent specifically as allergy. The main thing we did in 2002 practice, we believe, in allergy care provided by all 18 allergy: evidence
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell those professions. There is no conclusive evidence in, I think, something like 56 countries, which again is that we found that establishes that one particular suggesting that certainly for asthma—less clearly for model of service delivery outstrips others. other allergic conditions—it is the UK, Australia, Nevertheless, although there are these pockets of New Zealand and the Irish Republic which are, good practice, undoubtedly, the evidence, including again, up there at the top. So there is some the views of the many stakeholders with whom we international research eVort going on to collect engaged on the review, does suggest that there is relevant data on prevalence and incidence. scope for improvement in the areas that you have highlighted. There are undoubtedly, as we have Q14 Baroness Platt of Writtle: Do General found, gaps in current knowledge around issues like Practitioners have adequate training in allergy? service configuration, the best skill mix, the best Professor Marshall: Perhaps I could take that balance of generalist against specialist services and, question because, as a General Practitioner myself, I also, in data on cost-eVectiveness. We believe that the am acutely aware of it. I would say across the board next steps that we have set out in the report of our probably not, is the answer. If I just give an example review will help to address some of these issues. of my particular training: we had good training at undergraduate level in basic immunology and in Q12 Lord Broers: There does seem to be a problem applied immunology, and that has clearly got better with the data, does there not? The review concluded in the last 20 years: very good training in taking that the absence of baseline data on allergy services history, in making a diVerential diagnosis, and good made it diYcult to develop a strategic national view training in specific disease areas like asthma or like of how and where services could be developed. What dermatology. I think the areas of weakness, where steps have been taken to combat this? they exist, are, first of all, an awareness of allergy as Professor Marshall: We think that improving the data a potential diagnosis—I do not think that is as good is an absolutely fundamental thing that we have to as it could be—and, secondly, understanding some of do. We think that the best way of collecting data is the second line issues around diagnostic procedures at a local level. This is why one of our key and treatment procedures. So I think General recommendations, which perhaps we will come back Practitioners are very good at first line, simple to, is around improving commissioning. What symptom control but perhaps not in the more commissioning involves is a very clear needs complicated cases of allergy. assessment, so we would regard PCTs as taking the lead in assessing the needs by performing formal epidemiological assessments of the needs within their Q15 Baroness Platt of Writtle: Who is doing the local communities as well as prioritising those things training locally for them? alongside others. We hope that that, in conjunction Professor Marshall: For General Practitioners, with the other issue that I mentioned of a properly perhaps I could divide between higher specialist promoted National Code through Connecting for training, before somebody becomes a GP, and post- Health and SNOMED, will help improve the quality specialist training. In terms of higher specialist of the data that we have. training, the main people responsible for setting the standards are a group called PMETB a regulatory body with responsibility for setting standards of Q13 Lord Broers: Do you think this will allow us to training. They work very closely with the Royal collect basic demographic data in a standardised Colleges, and with the Postgraduate Deans. So they form? The thing that interests me here is your are responsible also for providing the specialist statement that we do not really know how we stand training. Once somebody has qualified and in with respect to other countries. Is there an eVort to independent practice then, again, the Postgraduate get together, for example, across Europe at least, to Deans play a role and there are a number of specialist standardise these data? allergy courses that General Practitioners can attend Mr Bell: We are aware of initiatives such as the around the country, particularly one in Southampton Global Allergy and Asthma European Network and one in Warwick, that have been around for some which is busy, amongst other things, collecting data years and are very highly regarded. on allergies across diVerent countries in Europe. Certainly the data that they have suggests, as Martin said earlier, that we are up there near the top of the Q16 Baroness Platt of Writtle: But not necessarily table (or bottom of the table, depending on which over all the country. way you look at it). There have been other research Professor Marshall: No, I think that is true, although studies done, some of which are still ongoing, such as people are very willing to travel to high-quality the International Study of Asthma and Allergies in courses like the Southampton and Warwick ones, so Childhood, which has looked at data from children I do not think they have to be in each locality. allergy: evidence 19
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell
Q17 Baroness Platt of Writtle: There are 13 million given to GPs to be on the look out for issues that may patients with allergic disorders, 7 million of whom not occur in diVerent parts of the country? would benefit from specialist care. To whom can the Professor Marshall: Do you mean regional diVerences patient be referred in the absence of a specialist in in the epidemiology of allergies or the provision of the area? services? Professor Marshall: It is an important issue, and I think it is, perhaps, where our allergy review came Q21 Lord Soulsby of SwaVham Prior: Regional out as rather diVerent from the recommendations in diVerences in the causation of allergies, more than the the Health Select Committee report and, prior to administration. that, in the Royal College of Physicians report in Mr Bell: Perhaps I could just comment on that. The 2003. They called very strongly for much larger epidemiological data that we pulled together for the specialist services, particularly a much larger number review did not show any clear diVerences between of specialist allergists. We could find no evidence that diVerent parts of the country in the proportions of that was going to be a cost-eVective way of using people who might develop diVerent allergic limited resources, and our argument is that what we conditions. We do not think that really is an issue. need to do is skill-up the primary care services far more. So our argument is that if primary health care Q22 Lord May of Oxford: If I could come back to teams, which include General Practitioners, practice the Review of services for allergy, it made some nurses and community dieticians as well, were recommendations and I would like to ask you about working well then actually the need for specialist two of the recommendations: what has been done services would be far less. Having said that, there very towards implementing them and on what timescale. clearly is a need for specialist services, and I think it The first suggested thinking about commissioning the is absolutely clear that there are inadequate specialist development by NICE (which I think is the National services at the moment. Institute for Health and Clinical Excellence) of guidelines for allergy, and the second Q18 Baroness Platt of Writtle: If you are going to recommendation was that there might be some work rely on the GPs and the practice nurses, which I think with the Royal Colleges on guidance for referral and is a good idea because it is local and near the people care. What actually has happened and on what who have the problem, where are they going to get timescale do you see that happening? their specialist training, if it is not available locally? Professor Marshall: Could I apologise for our use of They are busy people. acronyms; it is a disease that we all have within the Professor Marshall: That is a key issue, and I would Department of Health system. agree with you that it is something we need to look at. Q23 Lord May of Oxford: I apologise for not Q19 Chairman: Can I pick up on that and follow on, knowing it! because you cite the courses in Southampton and Professor Marshall: Yes, we regard the development Warwick, but my understanding is that most of the of guidelines as being one of the more important people on those courses are nurses, they are not GPs, of our recommendations. We have worked up and they are not actually providing clinical proposals which have been submitted to NICE in experience on those courses; they are not monitoring order to develop allergy guidelines. We have the practitioner’s clinical practice either even back submitted them to two of the NICE consideration at base. panels, to the Long-term Conditions Panel and to the Professor Marshall: You are certainly right about Maternity, Children and Adolescents Panel, and we most attendees being nurses rather than General understand that they are going to be looked at Practitioners, and I think in many ways that reflects around about now, certainly before the end of the the nature of the skill mix and delivery of primary year. If they agree that it is important, and our care over the last 10 or 15 years. I think you are understanding is that they probably will, then it needs correct that in terms of assessing the quality of to be taken to a national committee in January, services at a local level I do not think that happens which prioritises it alongside other demands for adequately at the moment. guidelines, and then taken to Ministers to be signed oV. If it is signed oV then the development of Q20 Lord Soulsby of SwaVham Prior: Pertinent to guidelines usually takes between 18 months and two GPs and their knowledge of allergies, are there years. So, as far as NICE is concerned, we have taken regional diVerences that GPs should be aware of, that action. We did make a specific recommendation in the North of England, for example, this is more about involving the Royal Colleges in developing common than something in the South of England? If further guidelines. We decided, after discussions with that is so, what special training and information is NICE, that it would be better for the Royal Colleges 20 allergy: evidence
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell to feed into the NICE process, so we do not have and chronic obstructive pulmonary disease are parallel processes going on. We have done some higher priorities for them than allergy services will be. specific work with the Royal College of Paediatrics and Child Health over developing care pathways, and we have just started talking to them. They are Q27 Chairman: You are asking them to commission apparently very keen on working with us, and that for services but without baseline data of the level of work will be taking place over the next few months. need. All you have got is that perception of demand, which may be quite diVerent to need. Professor Marshall: Commissioning is a complex Q24 Viscount Simon: Stephen Ladyman, in evidence process; it is not just about, as you are well aware, to the House of Commons Health Committee, said contracting for services. The first step of Y that he was going to ask the Chief Medical O cer to commissioning is needs assessment. We are asking V oversee an allergy “action plan”, in e ect to guide them to undertake the needs assessment first before and support local allergy commissioning. Do you they then decide what their local needs are. That know what has happened to that? process is not just about looking at the epidemiology Professor Marshall: Yes. As a Government we are in their local areas, it is also about consulting with very committed to ensuring that any policies that we key stakeholders, of which we regard the public as make or any action that we take is based as firmly as being an absolutely key one. If the public regard possible on research evidence, and we felt there Y allergy as being a priority then that is something that was insu cient research evidence to take action the PCT will have to take on board. immediately after the House of Commons Health Select Committee. That is why the decision was made by the Chief Medical OYcer to undertake a further Q28 Chairman: Without the coding how can they review, and hence the review that we have submitted collect the data, without doing an original research to you. Now that that review has been published (it project, which they do not have the resources to do? was published in July) you will see a series of next Professor Marshall: They are going to have to look at steps or recommendations, many of which are in line other codes that might be related to allergy services. with and address the issues recommended by the It is the weakness and a deficiency, as we have already House of Commons Health Select Committee. identified.
Q25 Viscount Simon: Have any PCTs commissioned Q29 Chairman: Can I go back to another gap, any allergy services? possibly, that you have highlighted, which relates to Professor Marshall: To our knowledge, not yet—to training? If you are wanting GPs to undertake the our knowledge. We have sent them copies of the larger part of the services and there are not adequate review and we are going to be doing work with them, training courses for them (and indeed they are not on as we mentioned, on one of our recommendations them at the moment) then it seems that you have got around commissioning. an enormous amount of training to do, and yet if specialist services do not have the capacity to provide Q26 Viscount Simon: Do the local commissioners that training you do not have anybody to provide the have the money, the expertise and other resources— training which would be needed to get them up to the and I stress those words—to co-ordinate appropriate level to be able to provide the service. allergy services? Professor Marshall: I agree that that is a particular Professor Marshall: This is the key question. I think it issue. What we are doing is working very closely with is the right question because action needs to be taken the Royal Colleges and with the Deans to try to at a local level. Whether PCTs have the capacity address that issue. I think we are starting from a fairly or capability at the moment to undertake low baseline in terms of allergy services. One commissioning of the quality that we would like them specialist allergist committed to teaching can teach to undertake, I think, is questionable, although we many hundreds of GPs over a period of time, and are putting steps in place to support them and make therefore what we would expect is a cascade process. sure that they skill up much more rapidly. That is a So I agree that there are insuYcient allergists to be general issue in terms of commissioning. Specifically able to move things on very quickly, but we believe in terms of commissioning allergy services, it is up to that action can be taken. the local PCTs as commissioners to decide on the priority of allergy services alongside the many other priorities that they are going to have to look at. I Q30 Chairman: However, you do still need to have would not be at all surprised if PCTs decided that specialists coming up in the system particularly to cancer services, cardiovascular services, liver services replace those who take time out to do teaching. allergy: evidence 21
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell
Professor Marshall: Yes. subjected to much stronger quality thresholds and relevance thresholds than it is at the moment. Q31 Lord Taverne: The UK Health Research Analysis carried out by the UK Clinical Research Q33 Chairman: I wonder, Professor Davies, if you Collaboration analysed spending on health research could tell us how much research is going on into food in the UK, but because allergy is a multi-organ allergies and anaphylaxis? You have referred to disease it fell across several disease categories. What respiratory problems. should be done to ensure that you get a grip on the Professor Davies: We do not know and it is not data results of the research and that it does not suVer from we can get at. When we look at what we know we are being compartmentalised? funding, we fund a unit at Imperial for £2 million Professor Marshall: Perhaps I could ask Professor over four years looking at allergy and asthma; we are Davies to answer that question. funding five projects within the Health Technology Professor Davies: Thank you. I am glad you have seen Assessment Programme for a total of £2.2 million this report. I chair the UK Clinical Research and they are doing studies like comparing inhaled Collaboration and I am very proud of the work we corticosteroids with leukotriene receptor antagonists have done in this. It is the first time anywhere in the and, interestingly, a trial of ion-exchange water world that we have looked at how research funding softeners for the treatment of atopic eczema in is spent, and this takes in all the major public sector children. On reviewing the reports that we receive funders and the major charities. It was a very from hospital trusts for those allocations that are intensive, 18-month project and we split it down, as historical we know that there are five major you have seen, into a number of areas which did not programmes which are working in the allergy field, include allergy—you cannot do everything. Here, including Guy’s and St Thomas’, King’s College where the bits most relevant to allergy are Hospital, the Royal Brompton, Southampton and respiratory, what you will see was perhaps expected, South Manchester. However, to break it down but what was worrying was that when we compared further we cannot do at this stage. the research spend with the disease burden there was an imbalance. However, we cannot do much more in Q34 Chairman: My understanding is that the depth with the data because it is a limited data set that majority of those are respiratory-based. was collected there. What we are doing with most of Professor Davies: I can see from the data I have that the major public funders is continuing to categorise four out of the five are definitely respiratory-based. present and future spending in this way, so we will The Southampton one we do not have data on. collect that. I think the highlight around the respiratory, much of which is COPD or asthma, is Q35 Lord Broers: The indirect costs of allergic very important. That shows that there is an diseases are potentially huge. How does absence imbalance that needs to be looked at, but it is high from work due to allergic conditions compare to level. We are clearly doing a lot to try and make sure that of other conditions, for example back the funding goes where it should, and you will know problems, mental illness and repetitive strain injury? that at the end of January we launched the new Professor Marshall: The indirect costs are absolutely government strategy for health research in NHS, Best potentially huge. We do not have any good Research for Best Health, that opens up a lot of comparative data comparing issues related to funding opportunities in this area for allergy or other allergy with the other conditions that you mention. diseases where they need to do clinical research. One of the problems with allergy is that it does not tend to be a diagnosis that is put on sick notes, for Q32 Lord Taverne: What about the cost of the example, in the way that back pain might be. So we research? Research is national and goes beyond PCT do not have any direct comparative data here. I boundaries. How will this be accounted for when you suspect and hope that colleagues from the Health & have practice-based commissioning? Safety Executive might be able to give you more Professor Davies: Research is a national good, so it is data than we have available here. not money that we devolve down. Indeed we are, as part of Best Research for Best Health taking money Q36 Lord Broers: Do you think the Department of out that was given historically to hospital trusts— Health response to the diagnosis and treatment of over £500 million a year—being spent on research these conditions is proportionate to their impact on and supporting research, and putting it back totally work, education and quality of life? transparently over a three-year transition period. Professor Marshall: I think that is a diYcult question Where necessary that will be competitive, but all to answer in absolute terms. If all we are doing is transparently. So in the future we will know much looking at allergy services then I would probably better where the money is going and it will have been argue that our response is not appropriate. If we 22 allergy: evidence
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell compare it with other priorities then I think it is allergy and certainly continuing professional appropriate. education. It is something that we have to be very careful with; dentists are providing more invasive Q37 Lord Soulsby of SwaVham Prior: You may treatments, and it is a problem that we have to be have answered, in part, this question: what is the aware of. So patients tend to go to high street level of support given through grants under Section counters for their treatments. Is there any evidence 64 of the Health Services and Public Health Act that treatments of no particular value are being 1968 to not-for-profit organisations that support oVered over the counter in high street shops? people with allergy? Dr Ridge: In terms of the tests that are available Mr Bell: Perhaps I may answer that one. We looked over the counter, the regulation of that, as you will at that on the database and apparently over the last see from the memorandum, is largely based on decade we, in the Department of Health, have whether the product is a medicine or whether it is awarded grant funding under Section 64 (the general a medical device. For actual medicines, those that scheme of grants) to voluntary bodies in the allergy are classed as medicines—creams, and those types field totalling over £532,000. of things that are classed as medicines—those are regulated in the normal way. For pharmacy itself Q38 Lord Soulsby of SwaVham Prior: What are the there are professional standards in place which are criteria for receiving these grants? currently being revised as pharmacy undergoes, if Mr Bell: Essentially, the Section 64 general scheme you like, a revolution in terms of how care is gives the Secretary of State for Health the power to provided on the high street, and a new regulatory make grants to voluntary bodies in England whose framework for pharmacists should be with us next activities support the Department of Health’s policy year in terms of professional regulation. For other priorities. Needless to say, the competition for professionals we are likely to bring forward available funds every year is extremely strong and regulation of acupuncturists and herbal medicine as we give priority to applications with innovative soon as possible. We have also asked the Prince of proposals of national significance that will Wales’ Foundation for Integrated Health to develop complement statutory services and so help to secure voluntary self-regulation amongst a range of other the provision of high-quality health and social care currently unregulated professions. As far as and, by so doing, promote the nation’s health. pharmacy is concerned, can I say a word around pharmacists in terms of their training? The pharmacy undergraduate course contains elements Q39 Lord Soulsby of SwaVham Prior: You on allergy and conditions associated with allergy. mentioned approximately half a million in funding. Allergy is also in postgraduate training which is well To my mind that does not seem an awful lot of taken up. Therefore, I would expect a pharmacist, funding for what we are talking about. In answer to from a professional point of view, to be Lord Broer’s previous question it is a major recommending medicines or medical devices which problem, yet half a million seems an extraordinarily have a proven use. small amount of money to put into this. Mr Bell: You could certainly argue that. As I say, it is always very competitive who is going to get Q41 Lord Colwyn: I may be wrong but I recall that grants, but I could say that to my knowledge three the prescribing of antihistamine had to be done on organisations—Allergy UK, Asthma UK and the the script and now you can get it over the counter. National Eczema Society—have all had grants in Has that changed? That must make a lot of that period, and the main beneficiary out of the diVerence to the products that are available. three is Allergy UK, which has had four diVerent Dr Ridge: Absolutely. There are a range of products, grants totalling nearly £400,000. Section 64 funding licensed medicines, which are available over the is very much regarded as pump-priming; we do not counter. I think in the memorandum there is a figure look to fund, on the whole, the core administrative, which states that about £60 million a year is spent ongoing costs of these bodies; we are looking to help on over-the-counter therapies associated with them with particular projects. allergy.
Q40 Lord Colwyn: We hear, that levels of allergy Q42 Lord Colwyn: Can I come back to the problem have soared in recent years and that GPs, perhaps, of the complementary therapies, because this is do not have an ideal training and cannot always something of great interest to me. Of course, many cope with it and specialists are few and far between. of the complementary therapists are, actually, Having said that, I do want to put a word in for my regulated (you mentioned the ones who are looking own profession, that of dentists, because in fact I for regulation). Is there any evidence that treatment recall having a fairly comprehensive training on in a complementary way is harmful in any way? allergy: evidence 23
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell
Dr Ridge: I am not aware of any evidence that it Q46 Lord Taverne: You will be aware that when it is harmful. I guess we could look further at that. came to the homeopathic regulations introduced on However, homeopathy, for example, as I guess you 1 September concern was expressed by nearly all the will be aware, is a recognised system of medicine professional societies—including the Royal Society, and regulation, and in fact we have just brought the Academy of Medical Sciences and the forward new regulations around homeopathy in Pharmacological Society—that for the first time terms of the requirement for products to satisfy a regulations were being introduced which allowed safety and quality test, and those regulations came claims of eYcacy to be made which were not in on 1 September this year. scientifically tested. Is that something which is going to be part of future regulation or not? Some concern Q43 Lord Colwyn: The treatment of allergy is all was expressed to us at the seminar which was held about arming one’s immune system. That is the aim before we started hearing witnesses that there was of complementary therapies. I do not know if you some misdiagnosis or delayed diagnosis, and the would comment on that. Royal College of Pathologists seems to have Dr Ridge: In terms of whether complementary expressed concern that the regulation of non-NHS therapies cause any harm? Is that the question? clinics is not adequate and that misleading advice can be harmful and costly for patients. I hope these Q44 Lord Colwyn: Yes. representations are being taken seriously, and that Dr Ridge: I am not aware that they cause any harm. we are not going to resort to non-scientific Professor Marshall: May I just add to that? In terms approaches to medicine on something as important of direct harm from complementary therapies, there as allergies. is not a lot of evidence, but Professor Edzard Ernst’s Dr Ridge: You are right in terms of how the regulations are set up and in terms of their team in Exeter has done some interesting work Y looking at indirect consequences of using requirement or not to demonstrate e cacy. I think complementary therapies, particularly in terms of that you are right to be concerned. However, there delayed diagnosis and delay in receiving evidence- is clearly a need for complementary therapies, and based therapies. So there is some interesting the regulation of the professionals associated with evidence here but it is contested, I think it is fair those, I think, is in the process of being enhanced. to say. Lord Colwyn: I think it is very minor evidence on Q47 Lord Taverne: Enhanced but not in the way in that. which it was enhanced to promote the homeopathic industry in the recent regulations. I hope that the Q45 Lord May of Oxford: You must be aware that regulation will be based on scientific tests. Can we recently in the House of Lords, in the debate in fact have an assurance on that one? sponsored by Lord Taverne on the regulations on Dr Ridge: I would need to go back and talk to the labelling of homeopathic medicines, a variety of people about that assurance. I am sure we will people of expertise in various relevant walks of provide you with a note. life—the kind of expertise you find in the House of Lords—voiced very strongly the belief that the Q48 Lord Broers: May I ask whether there have regulations had confused anecdote with established been studies of the eVects of prolonged allergic canons of controlled scientific evidence in what was disease and the consequences of that? It would seem allowed on labelling. In the light of that, can we to me that severe asthma puts great strains on one’s have confidence that if you are going to move to heart. I am not an expert on this, I am an engineer, produce regulations for these alternative things they but it would seem rather obvious; I have watched will be done with a bit more thought and rigour? people with sustained asthma and it seems to put Dr Ridge: As you may be aware, there are great strain on their system, so anything that delays two existing reviews of healthcare professional treatment would seem to be harmful. regulation, at the moment. One is associated with Professor Marshall: There is evidence that untreated the medical profession and one with non-medical asthma can lead to long-term lung disease. So there professionals. Consultation on that has just finished is certainly evidence about that. Whether there is and the principles associated with both of those evidence in other areas of allergy, I am not sure. reports, I would imagine, would apply to certainly Professor Davies: No, I am not sure. Of course, long- the herbalists and the acupuncturists in terms of term bad lung disease can have an impact on the their statutory regulation forthcoming. As for the heart, but you go through the lung disease before others, if it is a self-regulatory system then I would you impact on the heart long term. There is evidence hope to see similar principles apply, but it is still a that we all recognise as clinicians, of the allergic skin self-regulatory system. conditions it can lead to, lichenification, thickening, 24 allergy: evidence
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell and itching and unpleasantness. So we are all aware training that is going to be demanded of them with of long-term consequences. Have I seen a study that these changes you propose. tells you the magnitude of that problem? No, but Professor Davies: Perhaps I could give you some this is not my speciality area; I am a haematologist. good news. As you will know through the UK Clinical Research Collaboration, we went through Q49 Chairman: Dr Ridge, could I follow up on the a process which acquired the name of Walport, from line of questioning that was directed at you Mark Walport, of looking at the training of clinical previously? If we look at the patients who go into academics and agreed with Modernising Medical their local chemist shop and ask to see the Careers a schema for training clinical academics pharmacist because they have symptoms that they which would be clinical fellowships and clinical believe to be allergic in nature, what training does lectureships. We are, at the moment, looking at the that pharmacist have to give the advice and bids from university/NHS partnerships for training recommendations that are given? these people and accrediting those training Dr Ridge: Pharmacists now undergo a four-year programmes. We have agreed 11 programmes in training programme at undergraduate level. I have allergy, which is not insignificant. confirmed with the Royal Pharmaceutical Society of Great Britain, who are the regulators of the Q52 Chairman: That is not insignificant, and thank pharmacy profession, that the components of you for bringing some good news to the table, allergy and treatment are within the indicative Professor Davies. Could I move back to government curriculum at the undergraduate level. It is also policy and just ask you how the policy is formed in within the pre-registration year. At postgraduate terms of giving advice to patients? For example, if level, the Department of Health funds the Centre for Pharmacy Postgraduate Education based at the we take the report from the Committee on the V University of Manchester, and they provide a series Medical E ects of Air Pollutants, does the of learning materials associated with allergy, and Department now advise the public that air pollution looking at the figures in terms of uptake it seems is an important factor in allergic disease? reasonable. Mr Bell: If I may answer this one, obviously in any area of government policy we would want to be informed by the available evidence. We believe that Q50 Chairman: Do they have any input from the having done the review of allergy services we have clinical experts in allergy? done a lot to provide evidence for further Dr Ridge: In terms of the Centre for Postgraduate development of policy on allergy. Referring to Pharmacy Education and how those packs are the particular report from COMEAP, my constructed, yes, is the answer to your question. I understanding of it is that that report showed that think it is also worth mentioning that as roles exposure to air pollutants does not in itself cause change within pharmacy (and, for example, asthma but it may produce a worsening of the pharmacists with a special interest will be with us symptoms. Our colleagues at Defra provide an air quite soon, clinical specialists associated with a pollution service on behalf of the UK Government particular speciality working alongside and within and the devolved administrations. That air pollution a network associated with specialists in a hospital service for the public involves making hourly environment), then I expect to see that those people updates available to the public through the Internet, will be accredited in terms of how their training will take place. That is a requirement. a freephone helpline and TV teletext, and those updates show the current levels of air pollution and air quality forecasts. Defra also issues hourly Q51 Chairman: It seems to me there is an enormous updates to the media and other subscribers. So there training load that is emerging in this session: is that information which we make available to the training of the GPs, training of nurses and training public about the levels of air pollutants. There is of pharmacists. Yet that requires a body of specialist also a free booklet which you can get through the knowledge to be informing that training process Defra website, which was produced by Defra in otherwise you will have constant repetition of what collaboration with us and some other government was the level of knowledge at one time but without departments, which will give you advice as a integrating all of the research and, indeed, being member of the public on what particular levels of involved in modern clinical practice, that will air pollutants may mean for you and your health. eventually become increasingly out of date. So there is a concern, I think, about the number of specialist services and specialists that will be brought forward Q53 Chairman: What about advice to pregnant and if they are going to undertake the amount of lactating mothers over diet? allergy: evidence 25
22 November 2006 Professor Martin Marshall, Professor Sally Davies, Dr Keith Ridge and Mr Alan Bell
Mr Bell: I am not an expert on that area. I know Q55 Chairman: Thank you. We are just about at the Department of Health has issued advice on that the end of our questioning. I have one thing, but area. I think that may be something we would need you may want to supply this as a supplementary to follow up in writing to you. later, and that is who is actually responsible for Chairman: It would be helpful because there are determining the coding with the disease codes? The questions over the evidence base for it and indeed, coding issue emerged early in our questioning. if it is no longer underpinned by the evidence base, Professor Marshall: A combination of Connecting whether it has been made quite clear that that advice for Health, and that is directly through the clinical should no longer be given to women who are lead for Connecting for Health, a gentleman called pregnant or lactating. Michael Thick, and the Chief Medical OYcer’s team, and I would take direct responsibility for that. So it is a combination of the two of us.
Q56 Chairman: Perhaps you might like to take away our concern about the current coding system. Q54 Viscount Simon: You talk about air pollution, Is there anything else you would like to tell us about which is a very, very wide term. By what is air being that you feel that, perhaps, you have not had a polluted? chance to explain adequately in the questions we Mr Bell: I would have to look at the COMEAP have put to you? report to narrow down which pollutants are being Professor Marshall: No, we are happy, thank you. talked about. There are all sorts of diVerent things Chairman: Can I thank you for coming. If there is in the air, and I would need to check what the details anything else that comes to mind, please feel free to are and what the Government’s air pollution service send it in and it will be published with your therefore gives you information on. I am sorry I evidence. Thank you all for coming and giving cannot answer that. evidence today.
Supplementary letter from the Department of Health At the oral session on 22 November, we undertook to submit additional material to the Sub-Committee on three issues—the proposed statutory regulation of complementary medical professions, advice on diet for pregnant and lactating mothers, and pollutants in the air.
The proposed statutory regulation of complementary medical professions The Government is committed to the regulation of acupuncture, herbal medicine and traditional Chinese medicine practitioners. We have set up a Joint Working Group, chaired by Professor Mike Pittilo, Chancellor and Vice Chair of the Robert Gordon University in Aberdeen, to prepare the ground for statutory regulation of these professions. The Joint Working Group draws together feedback from all stakeholders, whose involvement is crucial to achieve a successful way forward. Inevitably, this does take time. Experience of regulating new professions suggests that we are unlikely to be in a position to bring forward legislation until 2008–09 at the earliest. Once legislation is in force, practitioners in these three disciplines will only be able to practise if they are registered with the regulatory body. In order to do this they will have to satisfy agreed standards, such as holding recognised qualifications and/or evidence of safe and eVective practice. People will be able to confirm the bona fides of a practitioner by checking whether they are registered with the regulatory body, and will also be able to make complaints about a practitioner’s fitness to practise.
Advice on diet for pregnant and lactating mothers The Department of Health’s advice for pregnant and nursing mothers is set out in The Pregnancy Book and in Birth to Five, which are given free to first time mothers. Both provide information and advice on peanut allergy as follows: “if you, your baby’s father or any previous children have a history of hayfever, asthma, eczema or other allergies, you may wish to avoid eating peanuts and foods containing peanut products”. In general, women are advised to read food labels carefully and, if still in doubt about the content, to avoid these foods and also to check with a health professional about diet during breastfeeding. 26 allergy: evidence
22 November 2006
Our current advice is based on the conclusions of the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT), based on the best available evidence when it reported in 1998. We recognise that the then available evidence on development of peanut allergy during pregnancy and weaning was not conclusive but, noting the uncertainty and the potential for risk of life-threatening anaphylaxis, our advice on peanut allergy is precautionary. We are aware of ongoing research, by both the Food Standards Agency and other organisations, and keep abreast of emerging evidence. We shall ask the COT for further advice when a reasonable body of evidence is available, and will update our own advice as appropriate.
Pollutants in the air According to the 1995 report of the Committee on the Medical EVects of Air Pollutants (COMEAP) on Asthma and Outdoor Air Pollution, air pollution refers to the presence in the air of gases or particles of matter, which are not natural to the atmosphere at such concentrations. These are generally man-made, though the term also applies to unusual natural events, such as the eruption of volcanoes. The COMEAP report was confined to the eVects of non-biological pollutants. It excluded aeroallergens (pollens, mould spores), although it recognised that they are important causes of respiratory problems— including outbreaks of asthma—and, being to some extent influenced by man, could be included as pollutants. The main ambient pollutants which have been studied in relation to respiratory diseases are particles, sulphur dioxide, nitrogen dioxide and ozone. The bulletins issued by the Government’s air pollution service show current levels of air pollution and air quality forecasts. Measurements are given for ozone, nitrogen dioxide, sulphur dioxide, carbon monoxide and particles. 11 December 2006
Examination of Witnesses Witnesses: Mr Patrick McDonald, Chief Scientist and Director of Corporate Science and Analytical Services Directorate, Health & Safety Executive; Mr Steve Coldrick, Head of Disease Reduction Programme, Health & Safety Executive; Mr Chris Wells, Deputy Director for Special Educational Needs and Disability, Department for Education and Skills; Dr Peter Wright, Deputy Director and Principal Scientific Adviser, Health Work and Wellbeing Directorate, Department for Work and Pensions, and Ms Anne Kirkham, Head of Decent Homes Finance & Co-ordination, Department for Communities and Local Government, examined.
Q57 Chairman: Can I welcome you here to our first Ms Kirkham: I am Anne Kirkham and I am Deputy day of taking oral evidence for our Committee Director in DCLG responsible for Decent Homes inquiry. I would like just to remind you that this Finance and Mixed Communities. session is being broadcast and also that the individual Dr Wright: I am Peter Wright, the Principal Scientific Committee members have completed a declaration of Adviser at the Department for Work and Pensions. interests which is available to the public, so we will not be formally declaring our interests to you as we ask you questions. We will ask you questions and if Q58 Chairman: I would like to start the questions, if there are supplementary issues that you wish to I may, and it is specifically really for the Health and submit later to this evidence session then we will be Safety Executive and the Department for Work and very happy to receive them. I wonder if you might Pensions. In the evidence submitted to us you say start by each introducing yourself. that it is diYcult to estimate the proportion of Mr McDonald: I am Patrick McDonald, the Chief workers who have lung and skin problems that are Scientist at the Health and Safety Executive, and with actually allergic related—asthma and allergic contact me this morning is Steve Coldrick, who is looking dermatitis. I wonder what plans there are to try to after our Disease Reduction Programme. record accurately the number of workers who are Mr Coldrick: I am Steve Coldrick, Head of the Health suVering from these allergic conditions. and Safety Executive’s Disease Reduction Mr McDonald: If I may start with a description of Programme. where we get our data from. The lead data source for Mr Wells: I am Chris Wells and I am the Head of occupational illness is a population-based survey on Special Educational Needs and Disability at the self-reported work-related illness, and from that we Department for Education and Skills. derive population estimates. Despite using what is allergy: evidence 27
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham the biggest survey system available to government other members of the workforce and how adequate is statisticians, this picks up fairly few cases of their access to advice? occupational illness, and the bulk of those are Mr McDonald: I think there is a general issue here musculoskeletal problems and mental health where, certainly compared to other countries in problems. There are just too few cases of Europe, access to occupational health advice is not as occupational lung and skin disease in the survey on extensive. It is an issue that we need to consider, which to base any reliable estimates of particular particularly in the context of our EMAS statutory types of skin and lung disease, so we rely quite heavily duties. on the voluntary reporting scheme which is run for us by Manchester University, and it relies on GPs and Q62 Lord Taverne: To follow up, on the information other consultant specialists. The scheme is called The about those suVering from allergic conditions do you Occupational Health Reporting Scheme, and we also have any information about people whose genes may take into account other administrative data sources predispose them towards particular allergies like such as the Industrial Injuries Scheme, and it is on occupational asthma? these figures that our assessment of trends are based. Mr McDonald: Certainly there is a genetic That is broadly adequate for monitoring whether or component to allergies, things like hayfever and not we hit the Health and Safety Executive’s targets asthma do tend to run in families, but I do not think but it is not adequate for targeting our interventions the evidence base available to us is wide enough to be very closely, so we have just commissioned an able to tell specifically whether a particular genotype addition to the THOR reporting scheme which is is responsible for allergic reactions. based on GPs who have had occupational health training1, and we are rather hopeful that that will improve the accuracy with which we can report on Q63 Baroness Platt of Writtle: What action is the occupational asthma and contact dermatitis. There is HSE taking to prevent individuals from developing also a broader engagement by the Health and Safety occupational allergic diseases? My mind flies to Executive in trying to measure the awareness and hairdressers because there is no doubt about it there attitudes to specific health and safety issues within is a certain amount of connection there, is there not? firms and monitoring consequent improvements in Mr Coldrick: In fact, yesterday on the specifics health and safety outcomes. I hope with time we of hairdressers we launched the first National will be able to draw more firm conclusions on Hairdressers’ Day, which was aimed specifically at self-reported occupational asthma and contact dermatitis which, as we know, includes irritant dermatitis. contact dermatitis and allergic dermatitis, and that is one of our major target audiences in respect of skin disease which includes the allergic response. We have Q59 Chairman: Are these going to be GP indexed put together, if you like, an alliance of the people who practices that you are going to be using to collect supply the materials, the people who actually work the data? with the hairdressers themselves, the trainers, and Mr Coldrick: I cannot say for certain whether it is also looking at the local authorities who enforce. that, but what I do know is that we have to make sure What we have learned in preparation for this that GPs are fully aware of recognising particular campaign is that it is not straightforward. If I give conditions, and that is why there has been this you a specific example: some hairdressers feel that it training. It has been an issue of concern for some time is part of the job to have dermatitis and in some cases so I expect the training to be for GPs at the indexed asthma. In fact, we had an e-mail from somebody practices rather than for all GPs. who had been doing it for 34 years saying, “Stop whingeing and just get on with it and accept it,” so Q60 Chairman: Because it makes a diVerence. there is an attitude problem. The second problem Mr McDonald: Volunteers for the scheme will get that we have is that when it comes to taking what are extra training at Manchester University who are very sensible and simple precautions for protecting running the overall core scheme for us. against allergic skin disease, dermatitis, hairdressers and salon owners shy away from that because they Q61 Chairman: Right, and how can you ensure that believe that the customers will not like hairdressers to workers have access to occupational health services wear, non-latex disposable gloves. So this campaign and occupational health physicians across the board, has been about dispelling some of the myths, and to or are you now going to be relying on GPs who you get an attitude change, not only amongst the salon are upskilling, which raises the question, what about owners, not only amongst the hairdressers, but also amongst the clients, and that is the whole thrust of 1 The THOR network of reporting GPs was added more recently to the overall THOR scheme to capture a wider spectrum of the campaign of which the Hairdressers’ Day is a disease severity. part. The campaign goes up to 20 December, but we 28 allergy: evidence
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham are continuing because when you are talking about further external peer review as we have produced the behaviour and attitudinal change we measure that in figures. So our judgments on progress are published, years rather than weeks. along with our reasons for those numbers, as is the external peer review of what we are doing. What is Q64 Baroness Platt of Writtle: What proportion of important to us are trends rather than absolute employers comply with legislation to provide a safe numbers in what we do as an Executive. It is workplace for allergy suVerers and what procedures consistency over time which is the key criterion for are in place to deal with employers who do not us, for our robustness, and, as you say, THOR is the comply? lead source for occupational asthma and contact Mr Coldrick: It is very diYcult to answer the first dermatitis. We have asked Manchester University to question because within that there is a presumption do some further research and statistical modelling on that we know everything about everybody and that these figures. The data are not perfect but they are also there is a turnover of business from year to year, certainly robust enough to support the general so there are businesses which are in business now statements that we make about health and safety. which we and others do not know about, so it is very Again, we are trying to look at this on a wider basis diYcult to answer that question. What we do have, so we have a programme of evaluation that actually though, is a targeted approach. In the context of looks at the impact of our various interventions and hairdressers, if I may stay with that, we have got a assessing changes in good practice and changes in suite of approaches. First of all, we are trying to raise behaviour in our target groups. That way we hope to awareness and get people to understood causation have a much more beneficial impact on the and be committed, because it is just commonsense. prevention of occupational asthma and contact Part of that is for the local authority environmental dermatitis. health oYcers (who are the regulators in hairdressing of health and safety matters) who as part of the disease reduction programme are visiting about Q66 Lord Broers: The diYculty with trends is that it 20,000 hairdressers over the coming year. Initially does not help us with international comparisons they will be taking the bag of materials which will necessarily, does it, as we discussed with the previous demonstrate the use of gloves and moisturising witnesses, and you say the diVerences in cream, which is an essential component, but later in data collection procedures make international the programme we will be turning to enforcement. comparisons of work-related allergy prevalence We want to give everybody the chance first to see the problematic, so what do you plan to do about it? light before those who will not then need to feel the Mr McDonald: We are part of two EU working heat. groups—the European Statistics of Accidents at Work and the European Occupational Disease Q65 Lord Broers: According to your evidence The Statistics—trying to standardise the position for Health and Occupational Reporting Network have work-related illness and injury. It is hugely reported a decrease in new cases of occupational challenging because we have all got very diVerent asthma and work-related contact dermatitis in recent systems of collecting statistics and we have very, very years. How robust are these data? diVerent cultural norms in terms of what is reported Mr McDonald: As you will gather from the answer to in workplace health. Whilst I welcome having the first question I was asked, there is some variability established working groups, I do not think they are in this data and trying to find the numbers from the going to come to any useful conclusions any time generality of common, multi-causal illnesses is a real quickly. challenge for us. What we do is collect information from a fairly broad range of sources and carry out a semi-quantitative integration, which is a rather fancy Q67 Lord Colwyn: So are you assuming that way of saying it is a well-informed judgment, and everybody who has contact dermatitis or asthma we use the important lead source for each of those always goes to see a doctor? data and then use other sources to guide our Mr McDonald: It is a population-based survey. There interpretation. Because it rests so much on judgment, is a real problem with these multi-causal illnesses and we have been very keen to make sure that this work when somebody presents to the GP, the GP is not is peer reviewed, so we had a workshop at the necessarily going to think of occupational health as beginning of the revitalising health and safety the first cause, so that is why we rely on the self- statistics which started in 2000 to test the robustness reported survey which would have a tendency to of our approach. We subsequently then discussed the over-report but at least gives us some confidence that approach with the Government’s Statistical Service we are picking up a reasonable indicator of the Methodology Committee and then there has been prevalence of illness. allergy: evidence 29
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham
Q68 Lord Broers: You have set yourself a target of around £25 or £30 a week. In a number of instances reducing occupational asthma and allergic contact there will be, in essence, no permanent disablement dermatitis by 10 per cent by 2008 from a 2004 but the potential to become disabled, and that may baseline. What practical measures are you well fall below the 14 per cent threshold which applies implementing to meet that target? and means that no payment is made. In terms of Mr Coldrick: That falls to the Disease Reduction numbers, we are trying to get you some numbers. Programme. What we have within that programme That may sound a bit lame but this is an old and relevant to this inquiry are two projects, the rather small part of the benefits system and it is not respiratory disease project and the skin disease on our computer systems, so we are trying to see if we project, and we are targeting particular populations can get you some figures and if we can we will send with the highest incidence. Just as I referred earlier to them to you, but the answer in general terms is that hairdressers, which is one of our target audiences, we they are likely to be relatively low. As I have already are seeking to lead by working in partnership with all explained, there are considerable restrictions by key stakeholders and influencers, including role which people with allergic diseases are covered by the models, ie in the case of hairdressing, to actually raise scheme and, of course, they have to meet the the level of awareness, get the understanding, gain the particular criteria of prescribed diseases that come commitment, and achieve the behaviour change, and within payment at all, so the numbers will be low. In that is what the project is actually focused on. So it is general, numbers of people entering the scheme are a multi-stranded approach. It will be going through staying roughly stable overall. We still have a supply chain pressure, where possible, through trades situation that approaching 40 per cent are due to unions’ support, where that is relevant, education, to accidents. We are talking of no more than 10,000 new catch the people as they enter the particular target entrants a year and 40 per cent odd are due to sector, to make them aware as to what the right thing accidents. 60 per cent are due to diseases. Vibration is to do, and then also to raise awareness by those white finger and pneumoconiosis are the largest already in that particular target sector, to get them to numbers; allergic diseases are very small numbers. understand what they need to do and why they need There is no suggestion that there has been any great to do it, and in most cases why it is relatively simple; change in numbers, but that may not reflect the it needs an attitudinal change. Finally, of course there incidence of the disease because it is such a selective is always the regulatory enforcement role. It is what group that comes in. If we can get figures, and we you might describe as a best mix approach to those have asked for them over the years, we will provide particular sectors. them to you.
Q69 Lord Colwyn: Do you have figures for the Q70 Lord Broers: Could you give any details of what current level of industrial injuries disablement benefit retraining schemes or other schemes are available to being paid to employees from allergic disease and ease reduced earnings for these poor people who are what sort of shape is the graph; is it rising rapidly? unable to carry on their work? Could I also ask you at what stage is the employee Dr Wright: Reduced Earnings Allowance was in fact labelled as having an allergic disease? closed from 30 September 1990 so recipients either Dr Wright: The first part of that answer is the received it before that date or, if they are applying industrial injuries scheme essentially starts payments now, it is because they had an accident or a disease if disability or disablement is present on the 91st day, which started before that date. It is simply a payment so the first 90 days are not covered at all. Then after towards loss of pay. I stress the word “towards” that the level of payment will depend on the degree of because it still exists for the reasons I have disablement, and in most cases of people with allergic mentioned, and it was always capped, and in fact the disease that is likely to be relatively low. You have current maximum rate for Reduced Earnings heard earlier about the possibility of more severe Allowance is £50.84 a week, so it is only a partial disability through complicating asthma, for example, contribution. That is not to say that people who have and there the permanent disablement figure will be a disability are not helped within the system. One of rather higher. In general terms, given the fluctuating the things that happened when it was closed was that nature of the disease, the levels of payment are likely a parallel provision was made for anybody with a to be quite low. The standard for an 18-year-old and disability, so when Reduced Earnings Allowance was over at the moment who is 100 per cent disabled— first introduced as a Special Hardship Allowance it that is really severely disabled—will be £127 a week, only applied within the industrial injuries scheme. so we are likely to be talking about something Disability Working Allowance, which is now part of substantially less than that, probably if there is a the Employment Tax Credit, is available to anybody persisting disablement something of the order of 20 who has a disability which puts them at a or 30 per cent, where you are talking of something disadvantage in the labour market, so those who 30 allergy: evidence
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham cannot receive Reduced Earnings Allowance would Child Matters Change for Children programme have access to the tax credit system to help them. In engages in a whole wide range of departments, and terms of saying programmes to help people, obviously as far as this particular inquiry is concerned retraining and so on, that will be attached to the two departments, mine and the Department of Jobcentre Plus through the normal programmes for Health, are critical. One of the key parts of the people who are unemployed or people who have a programme is to ensure that in every local area there is health condition and are on Incapacity Benefit, and a Children’s Trust and that that Children’s Trust owns you will be aware that there are proposals to change a children and young people’s plan. That plan is Incapacity Benefit and the extent and the amount of basically a commissioning plan, it identifies the key help that is oVered to people on that benefit. presenting needs in any area, it sets priorities for delivering better services to meet those needs and critically, in relation to my Lord’s question, there will be Q71 Lord Taverne: I want to ask about anaphylactic a local workforce strategy agreed by the various emergencies in schools. The Anaphylaxis Campaign is partners that are targeting a particular training setting up a national training programme to educate initiative that is necessary, and indeed they may school nurses on allergies because it feels the commission it themselves. The other thing I ought to Government is not doing enough. What training is just mention—and I am not sure if the Committee has there for school nurses, and teachers for that matter, for got a copy—is we have recently produced some dealingwithsuchanemergencyinaschool? guidance called Managing Medicines in Schools.Itis Mr Wells: If I can take this question in a couple of parts, joint guidance from the Department for Health and the firstly just to answer it but then also to give you a bit of Department for Education and Skills. It sets out a wider context as to how we would expect health services framework in eVect for ensuring that there is eVective and educational and social care services to be thinking practice in schools to support children with a number generally about work strategies that may help the of allergic conditions, including those who are prone to Committee understand what we are about. First, as I anaphylaxis, and there is guidance and advice in there am sure the Committee are aware, all school nurses are as well which is of an information nature. trained nurses and many are qualified children’s nurses, and this means that they will all have had some training and experience in the management of anaphylaxis. It is Q72 Lord Taverne: Thankyouandwhatisthe true to say that many nurses working in schools have Department’s policy on the use of auto injectors by access to training courses run by the Anaphylaxis teachers and students? Campaign, which is a well-regarded course, and to a Mr Wells: We would not want those to be used, as it certain extent although the way the question was were, just on the teacher’s judgment but where there is framed is perfectly reasonable, I do not know that we a child who is prescribed an Epi-pen or some other should have a fear about them having to run a therapy, and there is an agreement between the parents campaign or a course because many such organisations and the school for a teacher to administer it in the case do just that. Lots of people will access courses run by of anaphylactic shock, and the appropriate training can the British Dyslexic Association or the National be delivered to that teacher, then we would support it. Autistic Society, so it is quite commonplace in fact for In other words, if we just step back again, the guidance organisations with a particular specialism to design and I mentioned Managing Medicines has as part of its run courses for the benefit of a whole range of ambitionthatwherewehavechildrenwithparticular professionals in diVerent services, and that provides medical needs that there is an individual health care them with an income stream, so there is a value in that. plan, and if that plan identifies that a child carries (or In addition, it will be the case that primary care trusts one is held at the school for) an Epipen or adrenaline and others will run courses which are relevant for shot treatment, then there is no reason why the teacher nurses to access as well. It is in fact the case that any should not deliver it. We would not advocate teachers nurse who administers an immunisation in a school just holding a stock of those “just in case” because they setting will receive anaphylaxis update training on an would not have the judgment, we believe, to decide V annual basis. That is a requirement of their own whether or not the child in front of them is su ering continuing professional development. School nurses from that shock or some other need. who are involved in the delivery of such immunisations and other access treatments who have a particular Q73 Chairman: In your answer you outlined the knowledge will themselves be engaged in delivering training for school nurses and, to a certain extent, for training to school staV. I said I would give you a little teachers, but I wonder what ongoing audit is there to bit of background context, if I might. There is a major make sure that they do have appropriate level skills government programme which is partly in answer to because we all know that you can take people into a another question that you asked the earlier bodies training programme but that they have learned to apply about inter-departmental collaboration. The Every those skills is not necessarily the case. allergy: evidence 31
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham
Mr Wells: No, that is fair comment. The answer to the the major causes of worry in this area. Specifically, question though has to be made through local against the background of the discussion we have just judgment because, to a certain extent, it is rather had in general, to what extent do you see a particular impossible for a central department to make a need to really ramp things up a little bit and address judgment as to what is the best way of developing the very seriously some of the questions which have been school’s workforce in 33,000 diVerent settings. What we asked, not just about ticking boxes of procedure, but are expecting every school to have are a number of making sure people really are on key for this? policies, including policies which are related to the Mr Wells: There are a few things, if I might. First of all, support for children with medical conditions, medical we would expect the parent of the child who has the health needs, and then to secure appropriate training particular allergy to ensure the school understands that for their staV on a needs basis. There is a significant the child has that particular allergy. If I can refer back amount of money at head teachers’ disposal for just to one of the answers I gave earlier, that is then the that purpose, to ensure that they are developing their starting point for agreeing an individual healthcare plan school workforce to meet a wider range of demands in for that child. addition to teaching and learning, which is obviously their core business. Is does rather depend on the Q76 Lord May of Oxford: None of these kids may ever locality. have eaten a nut or a seed. Mr Wells: If I can move on, they are going to have eaten Q74 Chairman: Is there a requirement for those skills one once. If I can at least work on the assumption that to be assessed regularly because you could take a school the vast majority of parents are likely to become aware and have people trained, the boxes are ticked, you then of a child’s allergy before a school is presented with the have a child who has an anaphylactic reaction, but reaction to not knowing. The first thing is to make sure although the boxes have been ticked the skills are not the knowledge is shared and the knowledge is there at the time? understood by a wide group of adults within the school Mr Wells: I would certainly agree that the key thing for setting so that if they see the incident, if they see the us is to ensure that there is a depth of understanding of reaction, they can react. The second thing, of course, is the need and the risk that the school is trying to address. to make sure that teachers generally are aware of the We are very, very keen to ensure that people do not just likelihood that certain nuts and other foodstuVscan have tokenistic strategies, tokenistic policies, against indeed give rise to a shock. I think it is important to which they tick boxes, indeed to that extent we are recognise, although I respect the question, that nuts are rather against model policies because they tend to not the only likely cause of anaphylaxis, eggs are, cows’ weaken people’s engagement in understanding what milk can be, fish can be, indeed I heard a reference particular risk they have in their setting and indeed to earlier on to latex, latex can be; you cannot ban ensure there is a wider ownership. In fact schools have everything that could give rise to a shock. What is got a number of statutory duties which we believe are important is that, first of all, there is a clear ensuring that school governors and head teachers are understanding that a child is at risk, that the child itself taking their responsibilities—basically to address the understands it is at risk, and that adults are looking for question as you put it my Lord Chairman—to ensure incidences that could give rise to it. In that sense, we are they have got staV who do have the necessary training. very clear as a general nature of training and updating It is a head teacher’s responsibility to ask themselves teacher’s knowledge that must be part of the school’s whether the cadre of teachers and support staV they expectation of itself and, indeed, that we are helping have is capable of delivering across a broad range of schools understand the need for good hygiene generally issues, not just allergy, if I can say so. because in extreme cases, as of course you will know, very allergic children could react to traces of allergens Q75 Lord May of Oxford: I have a question which, in which have just been left on furniture, et cetera. It is a a sense, is a continuation of this but in the specific rich question which requires a rich answer, I think, and context. If another of DfES’s good schemes goes well we are trying to make sure there is a good level of there is one category of an anaphylactic shock which is understanding across the piece. going to be on the marked increase, I would guess, namely the programme on transforming school food, Q77 Lord Colwyn: It is a question I probably should replacing unhealthy snacks with healthy foods. We all know the answer to. If a child is given a shot with an epi- know from the tabloids it is having what we might call pen and, in fact, they are just suVering from a “teething problems” with concerned parents turning up temporary obstruction, apart from an increase in heart to feed their kids junk food through the fence. But rate, does it cause any harm? supposing it does go well, then the snacks kids eat are Mr Wells: I am not competent to answer the question. more likely to be the sort of thing I have just been eating My understanding is in general no, and in general, in at the morning break, seeds and nuts, which is one of any case, back to the answer I gave earlier, even where 32 allergy: evidence
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham we do have a child where there is an agreement that the younger than five, every school to have an individual use of an epi-pen is advisable, there is also a care plan for that child, and there is an agreement requirement that a medical service is called instantly. I updated periodically to make sure that everybody think where we are being more careful here is that we do knows how to deal with that case on its own terms. It is not want to encourage the general use of that treatment quite critical, of course, that the family is involved in amongst untrained folk, and that is after all what these circumstances themselves. It is quite critical to teachers are. My understanding is that what I am saying recognise that some parents will encourage a greater would also apply to, for example, doctor’s level of school involvement in their child’s health than receptionists. They would not just use it without some others. Indeed, some might be actively resistant to the prior knowledge of its likely success. In relation to your school being involved in the delivery of the basic particular question, I am afraid I do not know the treatments et cetera. We have to try and respect all answertotheextentifitcouldcauseharm. those diVerent shades of opinion against a clear Chairman: If I might intervene, I think it is dose-related understanding that there is a health and safety so that if you give an overdose, and that would happen requirement on all schools, just as there is in any other if you used the wrong pen, the wrong dose for a public building, and there is a duty in the Education Act particular child, then you certainly could run into to promote well-being. problems, possibly cardiac problems too. They are not things just to be taken lightly. Q80 Viscount Simon: Going on one step further in this particular aspect, are other students or undergraduates Q78 Lord Colwyn: Would a school have supplies of made aware of the allergic conditions that some other diVerent pens with diVerent doses? students or undergraduates might have? Mr Wells: No, it is child-specific. Mr Wells: Not automatically.
Q79 Viscount Simon: Again, just going a little bit Q81 Viscount Simon: The Royal College of Paediatrics further, what procedures are currently in place to help and Child Health has expressed concern with the fact V students go about their everyday life with allergic that hay fever su erers under-perform quite regularly diseases in schools and universities? in their end of term exams in the summer. Is there any Mr Wells: If I can take the university bit first, if you do particular reason why these exams are held at the peak not mind, because it is a relatively short answer. They of the hay fever season? Should they not be changed? are adults and there maybe a number of diVerent Mr Wells: I think you have asked a question that is services which would help them manage their own asking me to undo centuries of history, and I rather conditions. To a certain extent, we would expect the suspect the answer is no. arrangements that would be made within the university to mirror those you would expect to find in the Q82 Viscount Simon: Not to mention the seasons of workplace. There is clearly an expectation amongst the year! adults that they would carry their own treatments and Mr Wells: It is historical; there is a whole host of they would be aware of their own condition. diVerent reasons. Accepting that it is a serious question, Nonetheless, universities are large institutions, they will seriously put, to which I do not have an answer which have access to health services, they will want to make is likely to change the examination timetable, with the sure they are promoting the well-being of their students, greatest respect, I think what is critical, from an and they may very well have their own arrangements. It educationalist’s point of view, is that we are, first of all, is not something that we regulate, however, or establish very, very clear that a teacher’s job is to diVerentiate the from the centre. As far as schools are concerned, there is way in which they teach across the year to help to suit a relevance to the answer I just gave. As a child becomes the child or the young person’s particular circumstances older it becomes an expectation that they will become and, secondly, that when it comes to exam times of more able to hold and indeed administer their own course, young people do have the right to particular treatment and every support should be given to that. support if they have a condition which is going to We would be looking to school nurses and other health seriously aVect their likely performance. The extent to professionals to work with the child, the parent and the which universities or schools make sure that they use school to ensure that as a child is able to take greater well ventilated rooms, not right by a source of pollen, I control of their own health, they are enabled to do so. guess is a local issue which I cannot regulate for, sorry. That might, for example, mean helping a child know where it can store certain medicines. Some medicines Q83 Chairman: I wonder if we can move on and are controlled, as, of course, you will know. My general possibly, Ms Kirkham, a question for you relating to point comes back to an answer I think I have given housing health and safety. I am wondering how twice already, so apologies, that we would expect every the Housing Health and Safety Rating System school, whether the child is five, 15, 19 or indeed regulations support local authority oYcers dealing allergy: evidence 33
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham with environmental health issues which aVect tenants terms of categories. Category one and category two who suVer from allergies? hazards have the more severe health or safety Ms Kirkham: If I may try and answer the question in outcomes for people. Where you have a category one two parts. First of all, very briefly I will try to explain or a category two hazard the local authority is able to how the Housing Health and Safety Rating System take action of diVering degrees of severity, depending operates and then how local authorities would how you look at it, from the simplest, which is simply implement it in relation to diVerent parts of the serving a notice on the person responsible for that rented sector. In terms of the Housing Health and building, called the Hazard Awareness Notice, Safety Rating System itself, it is a series of 29 diVerent pointing out there is a hazard and what action might hazards that you could find in domestic premises and be taken to remedy that, going right through to a which would impact on the health or safety of prohibition order which says all or part of that residents. If you simply look at the 29 hazards as building should be closed.2 prescribed in the regulations, none of them specifically relates to allergies, so allergy does not Q84 Lord Soulsby of SwaVham Prior: I think the appear on the face of the regulations. However, when final question is on your evidence, where you state you look at the operating guidance which supports that there would be cost implications for local the implementation of the Rating System, there are authorities and the building industry if control four hazards where the health outcomes specifically provisions were extended beyond those in Building relate to the possibility of allergic responses by the Regulations or HHSRS guidelines. What are these? occupants of the building. Of those four diVerent Ms Kirkham: Again, if I may give an answer in two hazards: the first relates to damp and mould growth, parts. They are two issues related to costs: one would which specifically references the impact of mould be extending the scope of either Building Regulations spores and dust mites; the second is in relation to fuel- or the Housing Health and Safety Rating System to combustion products where the impact of nitrogen cover a much wider range of potential allergic dioxide and sulphur dioxide is also referenced; the responses than the current regulations and guidance third relates to volatile organic compounds and the cover. If I take the Rating System, that is an evidence- potential allergic responses, and the final one is the based system and those assessing it are dependent on hazard which covers domestic hygiene, pests and the evidence that is available which determines a very refuse, which again picks up on allergic responses clear linkage between a particular problem in the some people might have to pests. Therefore, any local building and the likely health outcome. The evidence authority oYcer engaged in the operation and the for a number of other potential allergic things is implementation of the Rating System has their much weaker and we do not have that very strong attention drawn to the possibility of allergic base of evidence in order to help people come to a responses in relation to specific housing conditions. judgment. A cost would be in trying to establish and The system was newly brought into force in April this deliver that much broader and wider evidence-base. year. It is a much better tool than its predecessor, the That would be the first point. The second would be a old fitness standard, in helping assess the health and cost in relation to taking action. In terms of, for safety impacts of many aspects of a home on its example, the Building Regulations the provision of occupants. In particular, those implementing the adequate ventilation is a key aspect of reducing the Rating System in terms of what action they might possibility of health outcomes from mould, and an take, are particularly asked to look at the aim of the present regulation is to try and maintain circumstances of the individual occupant. It guides not more than about 70 per cent humidity in the people to diVerentiate between people in diVerent building, which tackles mould spores. To tackle dust circumstances. For example, somebody in a home mites, you would have to get humidity down to where there was evidence of mould, and therefore the something like 50 per cent. Ventilation systems to do possible hazard of mould spores, may take diVerent that would be more expensive to implement, it is action if the occupants of that home were healthy something of the order of £1,000 to £1,500 per young people as opposed to somebody who may be property. In addition, the more complex the asthmatic. That is very clearly set out in the guidance. ventilation system, the greater energy use of that In terms of how that impacts on specific people and system, and therefore there are other implications in specific conditions, if we take the private rented terms of the Climate Change Agenda by having sector, then a local authority would only become 2 The powers of local authorities to take statutory enforcement engaged in response to a complaint from somebody action following HHSRS assessments are available in respect of living in that property. They would then inspect the owner-occupied properties and those in the control of private property, determine what hazards were present, and landlords. In the case of properties in the control of local authorities and registered social landlords, HHSRS assessments determine the severity of those hazards in relation to form part of the Decent Home standard, which requires a the likely health outcomes. The hazards are graded in property to be free of category 1 hazards. 34 allergy: evidence
22 November 2006 Mr Patrick McDonald, Mr Steve Coldrick, Mr Chris Wells, Dr Peter Wright and Ms Anne Kirkham systems which consume considerable amounts of Dr Wright: The Industrial Injuries Advisory Council energy. advises us on the scheme, both the future of the scheme and the administration of the scheme and Q85 Lord Soulsby of SwaVham Prior: Is there any figures, such as we have them, are published and are system of including into new buildings guarantees looked at regularly by the Council. The Council has a representative there from the Health and Safety against allergic problems lasting a period of years, Executive who can feed back and it can be fed before the house or the building, whatever it is, gets through the Executive, as I understand it, to into operation? It may not be identified at the time environmental health oYcers insofar as they carry when it is built, opened and occupied but due to out health and safety inspections. I am looking at my damp and mould and the build-up of various things, colleague and fortunately he is nodding. due to poor building practice or poor architecture, it would become apparent in three, four or five years Q89 Chairman: It strikes me that you could have a time. Is there anything in the Building Regulations situation of someone claiming benefits with an that would look at that sort of situation? ongoing allergic-related disease and if there is Ms Kirkham: As far as I am aware, Building nothing done to modify the workplace or feed back Regulations will not specifically pick up those things to the workplace, you are never going to decrease if they occur later than 6 months after completion. If that morbidity. it was a significant problem, as all new homes are Dr Wright: There will be a feedback to the workplace covered by a guarantee, it is a question of whether a if we have a situation where somebody is claiming severe problem would be noted and the occupier and is at work because we would approach the would be going back to the builder to seek redress for employer, as part of assessing the claim, to ask the whatever that particular problem was. For existing employer their perception of what has been going on, buildings, you do have the Housing Health and what the exposure is, and so on and so forth. The Safety Rating System but, again, it would be assessment process obviously involves a claim from dependent on a local authority oYcer being brought the individual, and if the individual is still at work in in to look at that property to pick up whether there the workplace where the exposure occurred, then the are any specific problems. employer’s view would be sought. The employer would surely be aware that the allegation that Q86 Chairman: If you are talking about a ventilation occupational asthma was occurring in his workplace scheme costing about £1,000 per property, is that to had been made. install it? Q90 Lord Colwyn: You mentioned your four main Ms Kirkham: That is to provide the additional hazards from a list of 29, can I ask you whether ventilation over and above what is normally electromagnetic toxicity was included in that list at provided to reduce humidity to below 70 per cent. all? Ms Kirkham: I do not know. The guidance manual is Q87 Chairman: If you compare that with the cost of a relatively thick document so without looking back a hospital admission, that seems to be very cheap. at it I would not be able to say. I do not think it was, Ms Kirkham: On an individual property basis, yes, from my recollection, but we would have to confirm clearly it is a relatively small cost, but to put that into that to you.3 every single property where not every single property Chairman: Can I thank you all for coming and is occupied by people who would need that additional helping us by giving this evidence as we explore the ventilation, there are other ways people could do diVerent issues before us. I would like to invite you, that, by installing dehumidifiers themselves which, when you go away from here, if there are other issues again, are perhaps more cost-eVective. which you would like to draw to our attention, you are welcome to send them in writing. In the light of our discussion they will be drawn to the Sub- Q88 Chairman: Dr Wright, you were talking about Committee’s attention, and written material, like those people who are eligible for a benefit and I oral evidence and other written evidence, will be wondered how the information that you have over available to the Committee and published alongside people eligible for benefit, and indeed receiving the transcript. Thank you very much for coming benefit, feeds into the information to the today. environmental health oYcers in relation to the workplace in which they are working because if their 3 In the Housing Health and Safety Rating System, electromagnetic toxicity is included under “Radiation”, which exposure is decreased then the severity of their covers threats to health from radon, microwave leakage and allergic response will decrease? electromagnetic fields. allergy: evidence 35
22 November 2006
Supplementary letter from the Department for Work and Pensions When Mr Patrick McDonald, Mr Steve Coldrick and Dr Peter Wright appeared before the Committee on 22 November 2006, they promised to provide you with written supplementary evidence, which is enclosed. Data on the number of people claiming Industrial Injuries Disablement Benefit suVering from allergic diseases is included in Annex A. As Dr Wright explained at the time, the benefit has not been computerised so that data is neither as complete, nor as promptly available as for other benefits. In addition, the numbers claiming for allergic disorders are low, in part as most do not cause significant disability for at least 90 days and so reach one of the criteria for disability. In Annex B, you will find additional information from HSE in relation to absences from work due to allergic conditions.
Annex A Table 1 IIDB CASELOAD FOR “ALLERGIES”
March 2003 March 2004 (Provisional) Pensionable Working Pensionable Working Allergy All Age Age All Age Age
Extrinsic Allergic Alveolitis (B6) 130 90 40 130 90 40 Allergic rhinitis (D4) 2,150 1,120 1,030 2,140 1,180 960 Asthma (D7) 4,230 1,150 3,080 4,330 1,280 3,050 Contact dermatitis (D5) 3,880 1,740 2,140 3,900 1,840 2,060 Notes: Data shows claims/cases recorded as shown, there may be other allergy cases not included in the above. All data has been rounded, therefore figures may not sum to total. Table 1 Caseload figures are based on a 10 per cent sample and are subject to a degree of sampling error and should only be used as a guide. Caseload figures for March 2004 are provisional only and are subject to change. Working age has been defined as males below 65 and females below 60.
Pensionable age has been defined as males 65 and over and females 60 and over.
Annex B
The indirect costs of allergic diseases are potentially huge. How does absence from work due to allergic conditions compare to that of other conditions, for example back problems, mental illness or repetitive strain injury?
Additional information from HSE There is a wide range of estimates for total working days lost due to these conditions. However, stress, and musculoskeletal disorders, account for the largest proportion of the total number of working days lost due to work-related ill health, according to the Self-reported work related illness survey.
ESTIMATED DAYS (FULL TIME EQUIVALENT) OFF WORK DUE TO A SELF-REPORTED ILLNESS CAUSED OR MADE WORSE BY WORK, BY TYPE OF COMPLAINT, 2001–02
Type of Complaint Sample cases Days lost (millions) 95% C.I Central Lower Upper
Bone, joint or muscle problem —mainly aVects the back 380 5.5 4.4 6.5 Breathing or lung problem 86 1.1 0.7 1.6 Skin problem 30 0.2 0.1 0.4 Stress, depression or anxiety 637 12.9 11.2 14.6 36 allergy: evidence
22 November 2006
HSE does not have any data on the extent to which allergic disease in general gives rise to work absence. It does have information on the extent of sickness absence due to all types of self-reported work-related respiratory diseases from its population based surveys. An estimated 1.1 million working days were lost in 2001–02 from work-related “breathing or lung problems” but the relatively small number of cases on which this estimate is based means that the true extent could range between 700 thousand and 1.6 million cases. The reporting network of occupational health trained GPs within the THOR scheme mentioned in HSE’s evidence is collecting information on sickness absence and HSE anticipates that it will be able to provide information on sickness absence specifically arising from work-related asthma and contact dermatitis when it has been running for longer. science and technology committee: evidence 37
WEDNESDAY 6 DECEMBER 2006
Present Colwyn, L Rea, L Finlay of Llandaff, B (Chairman) Simon, V Haskel, L Soulsby of Swaffham Prior, L May of Oxford, L Taverne, L Platt of Writtle, B
Mar, C.
Memorandum by Professor Peter Burney, Professor and Hon Director Social Medicine and Health Services Research Unit; Deborah Jarvis, Senior Lecturer; Seif Shaheen, Asthma UK Senior Research Fellow Respiratory Epidemiology and Public Health, National Heart and Lung Institute, Imperial College 1. Definitions 1.1 Allergies are conditions that arise from immunological responses that are not of obvious benefit to the person experiencing them. The majority are mediated by immunoglobulin IgE. This is a normal part of the immune response which is of particular importance in protection against parasites. In a proportion of people this is too easily raised against other foreign proteins that are not normally harmful. These are mostly associated with airborne proteins from pollens and animals, including the microscopic house dust mites. These proteins are referred to as allergens. In children the response is often first seen against foods, though these often fade out as the children grow, though if they persist they can lead to severe reactions. 1.2 There are several clinical conditions that are more common in those who raise this type of response to common airborne allergens. These include rhinitis (hay fever), asthma and eczema. These are often known as “atopic” conditions. All these conditions are also found in people who do not appear to have an increased production of IgE, and not all people who have raised IgE levels have clinical consequences. The form of the disease that is not associated with IgE is often referred to as “non-atopic” or “intrinsic”. “Intolerance” is often used to indicate a non-immunological response particularly to a food, or is used when it is not known if there is an immunological basis to the condition or not. 1.3. In what follows we shall refer to raising IgE against specific allergens as “sensitisation”.
2. Increasing Prevalence 2.1 An increasing prevalence of asthma was first noted in studies of Birmingham school children, starting in the mid 1950s. Between these studies and the mid 1990s almost all studies that measured the prevalence of asthma or wheezing in children in the same population on two or more occasions found an increase. The findings were very consistent and amounted to an estimated doubling of the prevalence approximately every 14 years. There was less evidence on other atopic conditions but where there was evidence these also seemed to be increasing at the same rate. 2.2 There was debate as to the extent to which this was due to changes in diagnosis or reporting. From the early 1980s doctors have been encouraged to make the diagnosis of asthma and prescribe treatment, though this would not explain the increase in wheeze. Subsequent evidence has shown that the prevalence of sensitisation has also increased. This would in part explain the increase and confirms from a more objective measure that the increase is likely to be real. 2.3 Since the 1990s the recorded increases have been less consistent and for the first time there are some studies that have shown a decrease in prevalence in children. The evidence is not, however, entirely consistent. In the UK there was a significant fall in the prevalence of self-reported asthma and rhinitis, but not eczema, among 13–14 year olds. There was, however, no fall among 6–7 year olds. There are no measures of sensitisation. 2.4 The UK has a high prevalence of disease when compared with other countries. This is true for reported disease, symptoms and diagnoses and for markers of disease such as specific IgE to common allergens and airway responsiveness (a marker of asthma). Other places with a high prevalence include other English 38 science and technology committee: evidence
6 December 2006 speaking countries such as the USA, Canada, Australia and New Zealand, possibly indicating a common cultural origin. 2.5 In developing countries there is a much lower prevalence of allergic disease in the poorer rural areas. Such evidence as there is suggests that this is not due to a lower prevalence of sensitisation (IgE to specific allergens) though it is accompanied by fewer positive skin tests. Although the ISAAC study shows little association between per capita gross national income and the prevalence of rhinitis or eczema in children, very high levels of asthma are only found in the moderately rich or rich economies and the allergic forms of the disease (with positive skin tests against allergens) are also found more commonly in the richer countries.
3. Future Trends Although the more recent findings in children are encouraging, the prediction is that the problem will become worse still over the next decades. It is commonly believed that atopy is less common in older people than younger people because as they age people are less able to mount allergic responses. This interpretation is, however, based on cross-sectional studies that have examined younger and older people at one time. Longitudinal studies show little evidence that atopy disappears as adults age. This means that the prevalence of atopy and probably allergic diseases in older people is likely to increase over the coming years, reflecting the longer term eVects of the increases in atopy and allergic diseases that were reported for children during the late 20th century.
4. The Causes of the Epidemic 4.1 We have yet to discover what changes in western lifestyle and environment have been responsible for the rise in allergy and asthma over the last four decades. Clarification of the factors responsible should provide opportunities for primary and secondary prevention. The reason why the UK, along with other English speaking countries, has one of the highest rates of asthma and allergies in the world is also unknown. One unsolved puzzle is why only a proportion of individuals with atopy (as measured by skin test positivity or specific IgE in the blood) develop atopic disease (asthma, hayfever, or eczema). Some patients with asthma are not atopic, and the causes of this condition may be diVerent to those for allergic asthma.
4.2 Hygiene Epidemiological research over the last 10 years has been dominated by two main hypotheses. The hygiene hypothesis, proposes that the rise in atopy has occurred because exposure to protective infections in early childhood has declined, through reductions in family size and other changes in lifestyle. To date, there is no definitive evidence to support this and in parts of rural Africa, which are presumably “unhygienic” in this sense, there is no problem in raising IgE to environmental allergens such as grass. Nor are there convincing data to suggest that vaccinations, antibiotics, or changes in bowel flora have been responsible. Whilst the apparently protective eVects of growing up on a farm might be explained by infections resulting from animal contact, there are other possible explanations. Despite the lack of convincing epidemiological evidence, research is underway to see if giving Mycobacterial vaccines might reduce the severity of allergic disease, though the long-term safety of manipulating the immune system in this way is uncertain. The jury is still out on whether parasite infestation reduces symptoms of allergy and asthma; one recent trial has failed to support this idea.
4.3 Diet Evidence that the rise in asthma has occurred because of an increase in intake of n-6 relative to n-3 fatty acids has been unconvincing, and trials of fish oil supplementation (rich in n-3) have been disappointing. Alternatively, it has been proposed that the rise is attributable to a declining intake in dietary antioxidants. However, epidemiological evidence in support of this hypothesis is conflicting, and recent trials of vitamin and selenium supplementation in adults have been negative. Given the complexity of nutrition, and the many ways in which diet has changed in recent decades, further research is required to investigate the possible role of other nutrients and to see whether food-based interventions might hold more promise for secondary prevention. We know less about the role of diet in childhood. Birth cohort studies in the UK are underway to study the possible role of nutrition in pregnancy and early childhood to see whether this might lead to strategies for primary prevention. science and technology committee: evidence 39
6 December 2006
4.4 Other risk factors 4.4.1 In recent years many epidemiological studies have identified obesity as a risk factor for asthma in children and adults. At present we do not understand what underlies this link, but it seems unlikely that the relation is causal. Obesity is, however, associated with poorer lung function and this is a concern for those with asthma. It is clear that the obesity epidemic is a major public health problem in the UK which needs to be tackled for many health reasons other than asthma. 4.4.2 There is no evidence that the rise in allergy can be attributed to increases in allergen exposure in the home, nor that house dust mite exposure causes asthma. Trials of dust mite avoidance in the home have been unsuccessful in reducing asthma symptoms and, paradoxically, may even lead to an increase in allergic sensitisation in children. 4.4.3 Smoking is associated with wheezing in adults, and passive smoking and maternal smoking in pregnancy have been linked to asthma in children. However, smoking is unlikely to increase sensitisation and may even reduce sensitisation to some allergens. Air pollution in general has been declining sharply over the time of the increase in allergies, though some have speculated that the increase in pollution from traYc sources may have been responsible. There is little direct evidence for this. 4.4.4 Evolving areas of research include understanding links between paracetamol, a commonly taken pro- oxidant, and the pattern of disease in women and how this is influenced by sex hormones. There are reports of increased asthma in women who use hormone replacement therapy and in those with evidence of gynaecological morbidity.
5. The Consequences of the Epidemic 5.1 The likely increase in allergy in an aging population raises several issues relating to public policy apart from the obvious need to provide adequate services. Those who are allergic are more vulnerable in many ways and with almost half of the population now being at least to some extent sensitised to common allergens, this needs to be taken into account when setting standards in several areas.
5.2 Treatment Although treatment is not the subject of the current review it is important to point to the evidence that good treatment may also be preventive of later problems. One of the primary goals of the treatment of asthma is the maintenance of good lung function. One of the most important treatments for asthma is inhaled steroids which have been shown in randomised controlled trials to reduce symptoms and improve quality of life. Long term randomised controlled trials to look at their eVect on lung function over a long period of time are unlikely to be performed as their eYcacy in the short term renders the use of “placebo” over a prolonged period unethical. An observational study of young adults has however shown that over a period of eight years regular use of inhaled steroids is associated with a lower rate of lung function decline especially in those who have evidence of an allergic aetiology (raised total IgE) for their asthma.
5.3 Indoor environment and home ventilation 5.3.1 Most adults spend substantial amounts of their normal day indoors. Good quality indoor air is imperative for good respiratory health although randomised trials to demonstrate this clearly are lacking. Adults living in homes with mould report more asthma symptoms, particularly if blood tests show they are allergic to mould species. In the UK we have shown that the use of gas for cooking is associated with more symptoms particularly in women, particularly in those who are allergic to allergens and particularly in those who do not ventilate their homes by using doors and windows. People who regularly open their windows at night also have lower levels of dust mite allergen. Good ventilation is required for good respiratory health and this may be a particular issue for those who are allergic. The current emphasis on household energy eYciency may lead to lower standards of ventilation and the implications of this need to be reviewed. 5.3.2 Unpublished work suggests that people with atopy who are exposed to cats have more reactive airways (bronchial hyper-responsiveness), most likely because of worse “airway inflammation” than those who are not atopic, even if they are not specifically sensitised to cats. As cat allergen is very pervasive (it is found in homes that do not own cats) this raises a diYcult problem of how to deal with exposure of an increasingly allergic population to general allergens. 40 science and technology committee: evidence
6 December 2006
5.4 The outdoor environment Currently air quality standards are set in relation to their eVects on cardiovascular morbidity and mortality, where the eVects are very clear. Despite common beliefs the eVects of air pollution on asthmatic patients are not clear. There is some evidence that allergen in air may be important for patients with asthma. Mortality from asthma in the summer months, when allergen levels may be high, is high among young asthmatics who have the highest prevalence of allergy. Rarely major outbreaks of asthma have been observed when levels of allergen in the outdoor air are very high. There is further evidence that there is a continuous low level of eVects from allergens in air, but the nature of these allergens is uncertain. Many of these would probably be very diYcult to control, but some are likely to be from man-made sources and need further investigation.
5.5 The work environment 5.5.1 It is estimated that around 10 per cent of patients with asthma have asthma that is of occupational origin. With an increasingly allergic population this is likely to be an increasing problem. It may be compounded by the fact that many processes are now carried on in small firms where problems may be more diYcult to identify and where there is less likely to be a professional occupational health service. Almost 3 per cent of young adults in one study said that they had had to change a job because of breathing problems at work. 5.5.2 There are occupations that cause respiratory problems that are due to exposure to irritants. These are not specifically associated with allergies but may be important as some of the exposures are common and found in dispersed workforces such as cleaners. 5.5.3 The recent banning of smoking in the workplace will certainly have made the workplace more tolerable for allergic members of the workforce and is extremely welcome.
5.6 Diet 5.6.1 The role that diet has in possibly contributing to the asthma epidemic has been outlined above. This eVect is still controversial but may be important not just in the causes of allergy but also in maintaining the health of those who are allergic. 5.6.2 Less controversial is the problem that food allergens pose to those who are sensitised to them. Food allergy has important consequences for those who suVer from the condition, for their families and for food manufacturers, and caterers including, for instance, those providing school meals. This is in part because the consequences of ingesting hidden allergen can, on rare occasions, be catastrophic. The steady increase in the rates at which people are admitted to hospital for food allergy and anaphylaxis probably reflects the general increase in allergy in the population.
6. Priorities for Further Research
6.1 Monitoring of trends It is important to know what the trend is in sensitisation, particularly in children and among the elderly. It is also important to know more of the eVects of allergy among the elderly.
6.2 Early life environment Evidence is accumulating to implicate the environment in utero and infancy in the aetiology of asthma and allergy. A number of birth cohort studies are under way which will hopefully shed further light on causes of asthma and allergy which operate during pregnancy and postnatally. The ultimate goal is to devise strategies to modify the early life environment in order to prevent asthma and allergy developing in the first place.
6.3 Gene-environment interaction One promising way forward in epidemiology is to identify interactions between genes and environmental/ lifestyle risk factors. If relevant gene variants can be shown to modify the eVect of such risk factors this provides more compelling evidence that the risk factors are causing allergy or asthma. science and technology committee: evidence 41
6 December 2006
6.4 Occupational asthma A priority area of research should be occupational asthma. This is under-recognised and makes a substantial contribution to the total burden of adult asthma. Furthermore, it is amenable to prevention and “cure”— removal of relevant allergens from the environment will lead to improvement in asthma symptoms.
6.5 The effects of outdoor allergen More needs to be known about the eVects of outdoor allergen, its sources and the eVects that it has on sensitised individuals.
6.6 Adolescence For many children, asthma seems to “go away” during adolescence, for reasons which are unclear. We need a better understanding of the natural history and prognosis of asthma through adolescence, a time when physiology and lifestyle change markedly. Improved understanding of “remission” may lead to opportunities for prevention.
6.7 Gender The relation between sensitisation, disease and gender is still poorly understood as are the consequences of increased exposure to endogenous, therapeutic (oral contraceptives and hormone replacement therapy) and environmental oestrogens.
6.8 Trials Definitive evidence on whether risk factors are causes of asthma and allergy can only come from randomised clinical trials—the setting up of a respiratory/allergy trials network in the UK, or more widely, would facilitate recruitment and faster completion of trials.
7. Further Reading [not printed] 3 October 2006
Examination of Witnesses Witnesses: Professor Peter Burney, Professor of Respiratory Epidemiology and Public Health, Imperial College, London, Professor Aziz Sheikh, Professor of Primary Care Research & Development, University of Edinburgh, Dr Graham Devereux, Consultant at the Department of Environmental and Occupational Medicine, University of Aberdeen, and Professor John Warner, Professor of Paediatrics, Imperial College London, examined.
Q91 Chairman: Can I start by welcoming you here Dr Devereux: I am Graham Devereux. I am Clinical today? Thank you for coming to give evidence to us Senior Lecturer at the University of Aberdeen, and as a committee. We have a members’ note of our I am a respiratory physician at Aberdeen Royal declared interests so we will not be going round Infirmary. declaring our individual interests as a committee Professor Warner: I am John Warner. I am Professor today. We will ask you questions and there may be of Paediatrics at Imperial College, having moved supplementary questions to the main questions as from Southampton only four months ago where I we go through. I wonder if you would like to start was Professor of Child Health. My special area of by introducing yourselves. interest and expertise is in early life origins of Professor Burney: I am Peter Burney. I am Professor allergy. of Respiratory Epidemiology and Public Health at Imperial College. Professor Sheikh: I am Aziz Sheikh, Professor of Q92 Chairman: I wonder if I might start with a Primary Care Research & Development at the question to all of you. In written evidence we have University of Edinburgh. had described the progression from eczema and 42 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner food allergy in infancy to asthma in the pre-teen Q95 Lord Taverne: Just following that up, you years as the “allergic march”. I wonder if you could mention in your paper that 80 per cent of asthmatics explain to us what are the mechanisms of the allergic tend to lose their allergy during puberty and then march and how we can halt it. start recovering some of it again. Have you any idea Professor Warner: It is a clinical observation that why that might be? many infants who develop food allergy and eczema Professor Burney: I do not think that I said that. go on subsequently to have asthma and allergic That might be from someone else’s paper. Maybe. rhinitis and there appears to be a progression from Professor Warner: Perhaps I can add a bit to that. one disease to another which has been termed the There are infants who show various food allergies “allergic march”. Whether having eczema per se who lose their allergies once they get to four, five, makes you more likely to go on to have asthma I six years of age. However, once they have reached think is not clear because it is more probable that about seven to eight years of age, if they retained there are common underlying factors that the allergies then in general they persist for predispose you to both conditions, but for some evermore and they might actually increase the range people they only inherit and are exposed to of allergies. However, even amongst those who lose environmental factors that predispose to one and sensitivity, say, to egg or to milk, which is very not the other. At the moment we are still unclear common in infancy and less common in older about all the mechanisms that are involved in the children, they are still at higher risk of developing generation of the individual diseases within that new allergies to inhalants like house mites and pollens. As far as adolescence is concerned, yes, allergic march, but one thing we can say for certain there is no doubt that particularly boys tend to is that if an infant starts with evidence of allergy improve their asthma and many of them lose their there is a very high probability that they are going symptoms, although the majority, if you do to show one or more problem associated with that. sophisticated lung function tests, still show an abnormality and many of those come back in their Q93 Chairman: You suggested in your answer that late twenties with a recurrence of problems. We there are certain unknowns about the origin and think part of that is physiological in that the lungs progression of allergic disease. I wonder if you could are at their best in early adulthood and, as they highlight where you feel the main unknowns are and begin to lose some of their elastic recoil with age the how we could find out about them. problem shows itself again. Professor Warner: I think we have got a long way in identifying the genetic components. What we do not Q96 Lord Taverne: The suggestion seems to be that know is how genetic factors interact with there is still a net decrease after puberty. Only some environmental factors in individuals, to lead to then develop the allergies again. Is that right? disease, so it is focusing on how the geno-type is Professor Warner: It is always very diYcult. The influenced by the environment to create the clinical problem is that paediatricians lose sight of their manifestations. patients. I think it has been said that they are more likely to outgrow their paediatricians than their asthma. From the longitudinal studies a pretty high Q94 Chairman: Do people suVering from allergic per centage, even of milder asthmatics who lose disease ever lose their sensitisation? their symptoms in adolescence, by 30 have had a Professor Burney: Not once people have become recurrence of symptoms, not necessarily as severe as adult. People tend to accumulate their sensitisation they were in childhood but certainly they are during childhood and early life. One of the things wheezing again and they are requiring some that is noted in cross-sectional surveys is that older treatment for their asthma. people have less allergy, but the important thing is that if you follow the same people as they get older Q97 Chairman: Are there any specific measures you they do not generally lose their allergies. The feel should be recommended routinely for children to explanation for the lower prevalence of allergies in prevent the development of asthma and eczema? older people is that people who were born towards Professor Warner: I would love to be able to say that the beginning of the 20th century tended to get less there were measures right now that one could allergy during their early years, so they are people recommend but there is none other than saying, “Do who never became very allergic rather than people not smoke in pregnancy”, and, well, “Do not ever who have lost their allergies. The importance of this smoke”, not only because of the adverse eVect it has is that it helps us to predict what will happen to the on the child’s health but also because of the bad allergic epidemic that we have at the moment and example it sets for the children who then take up how soon it will start to subside. smoking themselves, which in turn increases the risk science and technology committee: evidence 43
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner of relapse of asthma if it has improved. Other evidence now from a few randomised control trials to reasonable recommendations are “Sustain a good show that this can halt the progression of allergic diet”, and, “Breast feed if at all possible”. I think problems and the other area that seems quite beyond that at the moment we do not have enough interesting and promising is looking at the role of evidence to make any other statements. pro-biotics. This involves giving particular forms of lactobacillus and bacteria in early life, perhaps in combination with other approaches, and again there Q98 Lord May of Oxford: Can I ask a question in is early evidence that these may be promising this context for which one of the data points is interventions, but overall as we are advocating myself? When I was 12 I missed half the school year intervening in healthy individuals at the moment with asthma and since the age of 18 I have essentially before they have developed any disease in early life never had it, and I know other people like that, so the burden of evidence for intervening is very high if may it not be that the word “asthma” embraces quite we are advocating primary prevention strategies. a wide range of things? It is not something like What underlies this is that we are at the early stages measles. There will be some that are allergy based and Y in terms of our understanding of which interventions some that have other bases, so it is di cult to make work and there needs to be far more work done in generalisations. Is that true? building on those early trials. Professor Burney: I would agree with that. One of the Professor Warner: This is a very diYcult area. confusing issues, particularly in childhood, is that Recently there has been a meta-analysis of all studies there are a lot of other conditions that are probably of using hydrolysed milk formulae in allergy not allergic which make people wheeze. The view prevention and, whilst there are clearly some trials generally is that these are very common in infancy which have shown an impact, at the moment the and in very young children, but I suspect that they conclusion is that more work is required. It is a actually continue for a bit longer than that so that promising area, but before making recommendations throughout childhood you have probably got a in particular groups there is a lot more research to do; mixture of people with other conditions, just as in V likewise with pro-biotics but now the more exciting older life you get people who get rather di erent area looks to be pre-biotics, that is, just creating the wheezy conditions which can be confused with right environment in the gut for organisms to grow asthma, so I think your distinction between those normally, and there are one or two trials in process at that have an allergic basis and those that do not may the moment and one has just been published with well be a good distinction. One other thing which I what looks like very good results. think is sometimes missed, at least in relation to more severe disease, is that asthma gets worse among women during the child-bearing years so that from Q99 Lord Colwyn: You covered the point about puberty up to the menopause women probably have smoking and breast feeding. I pulled something out a worse deal during that time of their life than at of The Telegraph a month ago saying that there is other times of their life. evidence that maternal diet and maternal exercise are Professor Sheikh: As the Committee may be aware, important in the development of the child’s in uterus The Lancet recently published a very provocative lungs. Is that correct? Are you aware of that? editorial saying that the term “asthma” has outlived Professor Warner: Yes. Dr Devereux has done a lot of its usefulness; it is far too crude a term, so I think in work in that area as well, but that is nutrition rather due course we will have a more refined understanding than trying to avoid food allergens. There are lots of and a more refined range of terminology because it is nutrients that may be important. Dissecting out very much a catch-all at the moment. In relation to which are important is what is diYcult, but Dr primary prevention strategies, which you were asking Devereux can answer that question better. about, to try and stop the initiation or halt the Dr Devereux: The work we have been doing in progression of the allergic march, as Professor collaboration with people in America is that it looks Warner has said, the key recommendations that we quite promising that maternal diet during pregnancy would suggest are suitable at a population level,— is influencing the development of asthma in children. that is, taking all-comers,—are minimising exposure I am not talking about maternal ingestion of to tobacco smoke and breast feeding wherever allergens; I am talking about maternal ingestion of possible. However, we do have some clearly high risk nutrients, particularly vitamin E, possibly vitamin D families and in these families there are some and even zinc. There are now two studies showing interventions which appear to be promising. One in associations that low maternal intake of vitamin E mothers who are unable to breast feed, for whatever during pregnancy is associated with the increased risk reason, is the use of hydrolysed formula milk of children having wheeze, asthma, reduced lung preparation. What is happening there is that the function and increased markers of lung cows’ milk protein is being broken down. There is inflammation. The $64,000 question is what happens 44 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner if you intervene to change women’s diet in pregnancy, know what is happening to sensitisation in birth and that is a study that needs to be done. cohorts since then; that is important. We also need to know more about what happens to people who are Q100 Lord Rea: I wonder if you can bring us up to sensitised in terms of disease later on in life. There date about recent trends in the UK in the incidence would be a reasonable guess that things will get worse and prevalence of allergic diseases. because by and large as you get older you get frailer, Professor Burney: Amongst children the main you pick up more complications, you pick up more evidence comes from a study called the ISAAC study, problems, so we suspect that they would have more which is an international study that has studied disease as well as this added burden of sensitisation, children about 10 years apart and looked at the but we do not really know that and I think that will diVerence between not individual children but be important to know at the end of life. At the schools of children, so they are looking at the same beginning of life, as I say, I think it will be interesting age groups, 6 to 7 year olds and 13 to 14 year olds on and important to know what is really happening to each occasion. In the UK among younger age groups sensitisation rates. there were insignificant increases in asthma and rhinitis during that period, and there was a significant Q102 Lord Taverne: In your paper you mention that increase in eczema, but in the older children there there is this unsolved puzzle of why only a proportion were significant reductions in the prevalence of of individuals who test positive for specific IgE asthma and rhinitis and a non-significant reduction develop atopic forms of allergy. Is this becoming in eczema. That is important in a way and it has got more common or is this something which is a a lot of attention because up until those studies and complete mystery? Does this have an eVect on the studies published over the last few years almost all the development of allergies? studies that had looked at trends in disease had Professor Burney: As I say, it is a mystery. I do not shown upward for asthma, eczema and rhinitis, so it think that we know. Someone else on the panel may looks as if there is a flattening oV of this trend, though know more. There are some hypotheses about why this is not seen in all countries. In some places the some people seem to be able to carry an allergy and prevalence is still going up, in some places it seems to not have a disease as a result, but most of them are be going down, so for the first time there is a rather really quite speculative at the moment and people mixed set of evidence. That is for children. The other have been looking at why these things may happen. issue is the issue that I referred to a little bit earlier, I suppose the interesting results, which are not really and that is what is happening in adults. In adults, as relevant to the UK, are from places from where there I say, the picture is dominated by what happens from are a lot of parasites and in some of those studies cohort to cohort, in other words, from one birth there is a suggestion that the parasites will provide generation to the next, and what we know about is some chemical signal for the body to dampen down people born up to about 1970. We know in this group inflammation and that might be an explanation in that the prevalence of people who are sensitised to some places. Another reason might be, for instance, allergens has increased in each successive generation the diet, so that again we do not have a very specific and that these are therefore likely to be increasingly answer to that question but it may be that diet is aVected by the kinds of diseases that follow from important in your response to allergen if you have an sensitisation. We do not have that information for allergy. The short answer is that we do not know but children yet, so what is happening there is a bit of a I think it is a very important area to investigate. blank and we cannot answer the question of when this increase stopped. The ISAAC study, the study that I talked about earlier, did not measure Q103 Lord Taverne: Is it a high proportion or a very sensitisation. They looked just at the change in the low proportion of those who do not develop as you resulting diseases. would expect? Professor Burney: Quite a high proportion. I guess 50 per cent of the population probably in some age Q101 Lord Rea: What further work do we need to do groups will have sensitisation to a common allergen, in order to explain further these trends in children, but the proportion that will have recognisable adolescents and adults? asthma will be less than 10 per cent probably, so it is Professor Burney: Explaining why those changes have quite a high proportion. happened is an even more diYcult question. However, just to know how the epidemic is going to evolve there are two big issues that need to be Q104 Lord Rea: Are we making the best use, in reviewed. I have said that sensitisation is increasing looking into the epidemiology and course of allergic from generation to generation from people born in conditions, of the very considerable database that we about the 1930s to the 1970s. I think we do need to hold in the NHS, particularly general practice science and technology committee: evidence 45
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner records? Could we do more to make use of this Professor Sheikh: Certainly SNOMED has the information? potential to do that and the advantage of SNOMED Professor Burney: People certainly are using the data. is that it has been developed in the US, together with The data are becoming more available now and they the SNOMED CT version, the clinical terminology are more easily accessible. Perhaps Professor Sheikh version, which has been developed in association could say more. with the NHS. It is being used in about 40 countries Professor Sheikh: I will take this with your previous in the world at the moment and so in terms of question about disease trends. Building on Professor international comparisons through routine data sets Burney’s response, we know relatively little about the potential is phenomenal. It also allows more disease trends in the more severe systemic allergic specific coding because there is far more flexibility problems such as anaphylaxis, food allergy, urticaria, within this new coding structure in the way that the because a lot of the primary work has not been done. system is configured, so in terms of potential, yes. When we do begin to exploit these national data sets However, what I am slightly concerned about is that what we find is that hospital admissions for the at the moment we need to get the allergy community systemic allergic disorders have increased very involved in the range of terminology that exists to see rapidly over the last decade and a half, and these whether it is fit for purpose and I do not think that increases seem to be continuing. We are involved in has been done as yet. What also concerns me is that work using primary care databases to look at these for use in real time settings there needs to be trends to see whether similar patterns hold true and simulation work that as far as I know has not been these data also show that the systemic allergic done yet. Retrospective coding is one thing but, in disorders are increasing. What we also know is that terms of real term consultation coding, again, that multiple allergic disorders also seem to be increasing work needs to be done to see whether this system is so, whilst currently in the older age spectrum fit for purpose. We also need to ensure that there is approximately five per cent of people will have training in place because a particular advantage of multiple allergic problems, if we look in the younger this is that SNOMED CT through Connecting for groups it is something like 10 per cent. These are Health would be implemented across the NHS, so in some of the people who are getting into most primary care and in hospitals and NHS Direct, for problems and are running into most diYculties with example, and so we have a potential for linked data NHS care provision. In terms of unlocking the which is very powerful. What we need to ensure is potential of the data sets, we still have quite a long that there is consistent training across all of those way to go and one of the key things is allowing data diVerent NHS sectors to ensure that the data we linkage to take place, because not only do we have collect are ultimately meaningful because in order for healthcare data sets; we also have educational data Professor Burney and I to correctly interpret data it sets, we have got census records, so we can begin to is essential that these are collected accurately. look at the impact of allergic diseases if we can make progress on data linkage, but that needs some Q107 Lord Haskel: The problem with classifying thinking through because of the factor around data in this way, of course, is that if something new confidentiality and privacy issues. comes along you tend to miss it because it does not fall into any classification. Do you think there is any Q105 Chairman: Do you think the UK Biobank will danger of that? have a role here? Professor Sheikh: I think there is less danger of that Professor Sheikh: In terms of data linkage it could with SNOWMED-CT because it does allow you to possibly because it is going to be a vast resource and construct codes using a number of fields. Also, there the idea of linking with other national data sets is a commitment to this being an iterative process, so, would be very interesting. as with the current coding system, if there is a need there is the potential to include new codes, although at the moment this is quite a laborious process. With Q106 Lord Haskel: When we were discussing the SNOMED-CT it has been thought through a bit first question we spoke about the importance of better as far as I can see. defining terms. In oral evidence the Department of Professor Warner: In a way one of the problems in Health said that the introduction of the Systemised relation to feeding data into this system goes back to Nomenclature of Medicine, or SNOMED, as they the previous question that was asked about being call it, would help to classify allergic diseases in a allergically sensitised and having a raised IgE as much more specific way. Do you think that this will distinct from having IgE mediated disease. It is very improve the way in which clinicians and researchers easy for somebody to misinterpret information based exchange clinical knowledge and aid research into on a history and allergy tests in relation to the national trends? patient’s individual problem and then the data go in 46 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner incorrectly and that rather destroys the whole object that that is true. For the adults we have less of the exercise. That is a feature of allergy practice at information across the world, but certainly in the moment, not being something that is uniformly western Europe, and here we have evidence from included in undergraduate training or in serology, from looking at specific IgE to allergens in postgraduate education programmes, means that the sera from people from diVerent parts of Europe, there is not suYcient allergy expertise around to again the UK has, or rather in the centres in the ensure that the data feed-in in the first place is UK—I should be a little bit more precise because accurate. these are not universal studies; they do not try and Dr Devereux: As a chest physician I often see people capture the whole population of England—they had who are sent to my clinic with a diagnosis of asthma amongst the highest prevalence of sensitisation, and and a huge per centage of them do not actually have that was pretty well true for all of the centres that we asthma. This is where the database is going to looked at, and they had correspondingly higher levels collapse. It is so easy for a GP to make a diagnosis of of disease, so I think we can be pretty sure that that asthma because it is the commonest thing that is is true. The only places in the ECRHS, the European around, whereas when they come to my clinic I will study that looked at adults, which had as high or do the tests and find that some of them do not have higher rates of sensitisation were other English asthma; some of them have bronchitis and speaking places like Australia and New Zealand, emphysema, some of them are just overweight, so which had very high rates as well, so we can be pretty maybe out of 10 people I see with a GP diagnosis of sure about that. In the ISAAC study, which looked at asthma probably only about three or four of them more places worldwide, the other hotspot was Latin turn out to have asthma in the end, so you are right. America where they seemed to report very high levels, but for those we do not have the equivalent Q108 Lord May of Oxford: What do we know about data yet on sensitisation rates, so we do not have an the incidence and prevalence of allergic aZictions objective measure to measure that against, but that compared with other countries, and particularly, in will come. so far as it looks like we are high among the OECD countries, how much of this is real prevalence as distinct from diVerences in the definition of things we Q109 Lord May of Oxford: What are the ideas that are talking about or, more importantly, the statistics? are floating round about the underlying reason for Professor Burney: Again, most of that information our being higher than others? does not come from routine statistics; it comes from Professor Burney: There are a number of reasons. It Y surveys, so they are relatively well controlled. There has been very di cult to demonstrate a reason in a lot is a problem, obviously, in using questionnaires in of diVerent kinds of studies. When you actually get to being very precise about what people have and the data you say, “Let us adjust for the following whether the questionnaires are working exactly the things”, and then look to see whether that explains same way in one language as against another, but for the diVerence, and almost always the answer is that it the most part we can be fairly confident. If I go back does not explain it, so explaining the diVerences has to the ISAAC studies, which are worldwide studies of been extremely diYcult. There are general thoughts children, they are based on questionnaires around. essentially. Some of them are rather elaborate video questionnaires where the children are shown videos of something and asked, “Are you like that?”. They Q110 Lord May of Oxford: We have, of course, took quite a lot of trouble to try and take out the heard some of them. I wondered what your view of eVect of language problems that you might have. For their comparative merits was. the ISAAC studies it is quite true, certainly in Europe Professor Burney: I would probably at the moment that the UK comes high in the lists. In the six to seven put quite a lot of emphasis on diet. I think diet is year olds I think there was nowhere that was higher, probably important, but the detail of what in the diet if we include the Channel Islands and the Isle of Man is much more diYcult to disentangle at the moment. within the UK. I do not think there was anywhere There could be genetic diVerences. We know that that was higher in Europe for asthma and rhinitis in there are, but whether they are relevant in this case I the reports that were made from these am not sure. It has been noted, for instance, that by questionnaires. For eczema I think it was only and large genes follow language and quite a lot of the Sweden that had a higher prevalence. For the 13 to 14 places with high prevalence are English speaking. year olds, again, in asthma only Ireland was higher Against that the Australian centre in the ECRHS is and in rhinitis there were a number of places that Melbourne, where the population is very largely of were higher, but by and large the answer is that for south European origin, so maybe this is not a good those questionnaire-based data we can be pretty sure explanation. science and technology committee: evidence 47
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner
Q111 Lord May of Oxford: It is not really part of risk factors, that protect you from allergy are also Australia. associated with lower lung function, so it may well be Professor Burney: The other hypothesis that is causing that nanny is right, that playing in the dirt is not such a lot of interest at the moment is the so-called hygiene a good thing. It may be good for your allergies but hypothesis. Again, we are not entirely sure what it is you really need to know across the board what the in the hygiene hypothesis that is explaining the eVects are going to be before you start giving advice. diVerences. It is still really a hypothesis and, to be Professor Warner: I think the word “hygiene” is now truthful, it is probably lots of hypotheses which are probably the wrong one to use to explain this adapted to fit diVerent stories and I think that has to hypothesis. There was a very nice paper published in mature a bit. We need to know a little bit more about the journal that Professor Kay edits very recently exactly what it is about “hygiene” that is important. where it has been suggested by the authors, and I suppose those would be the two main hypotheses, indeed other people, that we should talk about diet and hygiene, that people are most interested in at microbial exposure or microbial deprivation the moment. hypothesis. Hygiene hypothesis gives out the wrong message to people, and the problem is that it is Q112 Lord May of Oxford: What about the playing interpreted as suggesting that you should roll your in dirt hypothesis? babies in dirt. The consequence is all kinds of Professor Burney: That is the hygiene hypothesis. nightmares of infections that we have eVectively There are a lot of separate bits of information about eliminated by good hygiene, and that is not what we that. Some of the early theories on mechanisms really want. It also gives out a very bad message, for do not seem to stack up so well but the basic original instance, in relation to immunisation. This is an area data were that if you have older brothers and sisters where there is enormous worry that families are not you are less likely to be allergic, and that seems to be immunising their children because they have got the very consistent in all the data sets. That was the message that immunisation means less infection, original part of the hypothesis. It has since been means more allergy. That is an incredibly bad public expanded in various ways so, for instance, one of the health message and we have got to counteract that. In interesting groups that have been looked at, mostly in fact, all the studies that are being done, and I have central Europe, is farmers and it is noted that people been involved with one that we are just putting who are brought up on farms, particularly farms with together a paper on at the moment, show quite the animals, are less likely to become allergic, which was converse, that if you immunise babies eVectively a bit of a surprise to some allergists who thought that there is, if anything, marginally less allergy. This is a being in amongst all those allergens might have had complex area and we have to disentangle all the the opposite eVect, but it does not seem to. That is a diVerent components. I still think it is an interesting strong part of that hypothesis. In other parts of the area in relation to potential for intervention but we world the hypothesis does not stack up so well. If you are going to have to understand what microbial go to Africa where the environment is completely factors are involved and how they can be diVerent hygiene does not seem to explain the distribution of disease. People have tried to explain it, administered to reduce allergies. for instance, by looking at parasites as part of this general hygiene hypothesis. In fact, parasites do not Q114 Lord Taverne: Is it the new Liu & Leung paper, protect against sensitisation, as predicted by the the paper you mentioned? V original hygiene hypothesis, but have a di erent Professor Warner: The paper I mentioned is by V V e ect and on a di erent part of the mechanism, so Bloomfield et al. I am sure Professor Kay would be V that is probably a di erent story. able to give you the details. It is Clinical and Experimental Allergy 2006, volume 36, pages Q113 Lord Soulsby of SwaVham Prior: Having 402–425. started oV on the hygiene hypothesis, I have two questions. The first one is what practical advice should the Government be giving to parents Q115 Lord Soulsby of SwaVham Prior: I just want to regarding hygiene to minimise the risk of their come back on the hygiene hypothesis. There has been children developing allergies? a suggestion that domestic pets, dogs and cats and Professor Burney: My view would be none. Again, we maybe other pets, play a role in this. Would you have been into this a little bit before. You have to subscribe to that? have a very high level of understanding of something Professor Burney: There is certainly some evidence before you start giving advice to people. One of the that children brought up with dogs have less things that people should be a little bit aware of is sensitisation. I think we probably need a little bit that there is a hint in some of the studies that the same more evidence to support it, but that seems to be true. 48 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner
Q116 Lord Soulsby of SwaVham Prior: Because this taking on westernised lifestyles and that is maybe country, the United Kingdom, has a high companion why the gap is disappearing now. animal population but it is not the only country in the European Union that does, of course. France and Germany have high populations too, and then there Q119 Viscount Simon: Or maybe second homes. is the reverse of that: countries that do not keep Dr Devereux: I suspect that if you are poor in Africa domestic animals because of religious reasons. What you cannot aVord a second home. is the issue there? For example, in a Muslim country Professor Burney: No, but movement between urban is there as much sensitisation and rhinitis as in a non- and rural areas does happen, particularly with Muslim country? children. Children will be sent from the towns in Professor Burney: I do not think we know much about some places to the country to be educated because it that. I should also add another issue over the pets, is a less dangerous environment, so that is a and that is that, again, there is misunderstanding complication. about this. Pets can be a problem for people who have already been sensitised, so they are not an undiluted joy in this way. I think the answer would be Q120 Baroness Platt of Writtle: Does everyone agree that in Muslim countries by and large they are often that the prevalence of allergic disease will continue to exposed to allergens but cats are kept outside the increase? house and therefore they have a much lower Professor Burney: As I was saying, I think it is exposure. That may not be such a good thing as some probably true in the older age group that that is people believe that very high doses of cat allergen almost inevitable, but I would hesitate in one sense. may be protective and lower levels are more likely to It is very likely to be true for sensitisation, for the sensitise but that is talking about the allergen, so reason I have given, that the younger adult there is a paradox about this. Cats carry allergen but generations of people who are now going to get older they also probably carry some of this microbial have a higher burden of sensitisation, so I think that exposure that might be protective as well, so it is a probably is going to happen. I would put a lot of paradoxical issue. I cannot really answer your money on that. I think the issue that follows from question about the countries in the Muslim world. I that, which we are less clear about, is what will do not have any data on that. happen to disease as a result of that increase in sensitisation. As I say, my guess would be that disease would also increase and be more of a problem, but Q117 Lord Taverne: Is there anything in the there is less evidence on that. suggestion “dogs good, cats bad”? Dr Devereux: The first data were with cats and most of the studies have shown that cats are beneficial; you Q121 Baroness Platt of Writtle: You talked about are less allergic to cats than you should be, but also the young compared with the old but would there be there is some dog work. On the stuV about Muslim adiVerence on a gender basis, males and females? countries, there is a study from Saudi Arabia showing Professor Burney: I think much the same for men and that Saudi Arabians, if they live in the cities, have a women. As I said though, there are diVerences very high prevalence equivalent to what we have in between men and women and I think, particularly in the westernised countries, whereas the ones living out the child-bearing years, women have a high burden of in the deserts with a nomadic lifestyle have a very low asthma. The answer to your other question, what is prevalence of asthma and allergic disease. It is not happening in children, is that we just do not know Muslim; it is where you live. It depends where you and that is going to be very important, but it will be developed or whether it was in the traditional very important for the more distant future. If there is lifestyle. genuinely a decrease in sensitisation amongst these generations, this will then reverse the trend, but in Q118 Viscount Simon: Is that the same in, let us say, another 20, 30, 50 years’ time. central Africa? Professor Sheikh: I think with this current generation Dr Devereux: In Africa there are studies showing very of children, where the data in the UK show that similar things, that populations living in the towns between and 30 and 40 per cent are experiencing and cities have more asthma and allergic disease. allergic symptoms, it is reasonably safe to predict that People living in the townships out in the bush are less this generation will continue throughout adult life to likely to have asthma and allergic disease. However, experience allergic symptoms of one sort or another, the first studies in the 1970s showed that there was so I think in the short to medium term the prevalence quite a big gap but now the gap is narrowing and it is is going to be high and it is going to have an impact thought that people in the townships and the bush are on all sectors of healthcare provision. science and technology committee: evidence 49
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner
Q122 Chairman: I wonder, Dr Devereux, if I could non-experts like GPs, respiratory physicians, pick up on what you were saying previously about dermatologists. These people are desperate for help some of the animals and whether it is true to say that and they are seeking help in alternative medicines, all being brought up with cats may give you tolerance, sorts of things, so one thing could be to try and but that there is a diVerent cohort who are allergic increase allergy provision so that a correct diagnosis and get very severe symptoms when in contact with of allergy is made so that the correct treatments can cats and they may be in the same house living with be instigated and the correct avoidance measures those animals? Have we got two populations? taken. Dr Devereux: I suspect we probably have. I suspect Professor Warner: I agree with what Graham that the way the cat protection phenomenon is Devereux has said. I think that is the most important explained is that when you get exposed to cat allergen thing. There are some other issues though. It is about your immune system responds with a toleragenic raising awareness across the whole of Government. response in that it tolerates the cat allergen, whereas For instance, recently the Department for Education you have got another group of people who, when has been recommending that the junk food which is they get exposed to cats, for whatever reason, genetic, sold in vending machines at schools should be environmental, diet, then develop an allergic replaced by nuts and peanuts as healthy foods. That response, so it is likely that you may have brothers is failing to consider the impact on the peanut and and sisters living together and one may derive tree nut allergic child in that school. It is a question protection and one may derive harm from the cat. of joined-up thinking between diVerent departments that might take account of this very common Q123 Lord Colwyn: We move on now to the burden problem. these diseases are causing. The incidence has obviously increased a lot since the 1950s and I think Q125 Baroness Platt of Writtle: What about the I have read in my papers that it just about doubles problem of children with rhinitis and exams, because every 10 years or so. in two lots of evidence it said that they are achieving Professor Burney: It doubles about every 14 or 15 one grade less due to their allergy? years. Professor Warner: Yes, very much so. There is now good evidence for that. Exams are virtually always in Q124 Lord Colwyn: The written evidence we have the middle of the pollen season and that brings down got has highlighted the significant personal, social grades appreciably. People have now done studies and economic impact of these disorders. Are there looking at results of mock exams, which are out of any key measures that you think perhaps the the pollen season, and comparing them with the Government or other public bodies should results that have occurred in the real GCSEs and implement to try and reduce this burden at home, at showing that pollen allergic children do drop a grade. school and at work? Professor Burney: I will have a first go at this. I think Q126 Lord Colwyn: I am surprised to have read in it is very diYcult, for the reasons we have given, to our evidence that there is not any evidence that the give very specific answers to that. Good healthcare increase is attributed to allergen exposure or even the would be good. Beyond that one of the things I would famous house dust mite at all. The gaps in our say is that it would be useful, given the high knowledge could perhaps be dealt with by having prevalence of disease, if this were something that was better training at undergraduate level, courses for always considered by departments when they develop doctors and more specialist allergists. Would that policy. I think that people tend to forget that there is solve it? this very large group of people who are specifically at Professor Sheikh: Undergraduate training is a key risk, so I think that if all government departments, issue. We have been looking in detail in Edinburgh at when they were developing policy, actually had a our undergraduate training provision. For example, check, “Have we thought about what the influence allergy diagnosis is not covered at all. Food allergy is would be on allergic people?”, that would be good. not covered at all in the curriculum. Multiple allergies As for giving very specific advice I would be pretty are not covered at all. This is a reflection almost much at a loss to give strong advice at the moment. certainly of what is going on in most other medical Dr Devereux: I think there is something that can be schools. At postgraduate level there is very little done. At the moment the allergy provision service in training provision at the moment. In response to your the NHS is not good. There is no allergist north of previous question, what else can be done, one of the Manchester. There is no allergy service for the whole pieces of work that we are currently doing is looking of Scotland or the north of England. What we have is at anaphylaxis management in schools. Schools are, a significant proportion of the population with on the whole, at a loss to know how to deal with this allergic disease who are getting ad hoc advice from problem. They are saying, “This is a healthcare issue; 50 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner we are educationalists”. GPs and, where they are of the chemicals have gone down, so it would be involved, consultant paediatricians are saying that it diYcult to link. The other aspect of this is your is not their remit to go into schools. Children are cleaning agents thing. There is a study from therefore falling through the gap. For those with life- ALSPAC associated with internal exposure to threatening allergies and with severe allergies one various chemicals and whether that needs to be all important step would be to think about case firmed up. Moving on to a diVerent phase of management. Case management now exists for a investigation, we have looked at the allergen phase number of other long term disorders. Everything and most people would accept that probably the needs to be done within an evaluative context because increase in asthma and allergy is not due to increasing there can be unintended consequences, but it would allergens. Dealing with the hygiene and the dietary be one step forward to begin thinking of these as long hypotheses at the moment, I think the things in the term disorders, which the NHS historically has not future are going to be the environmental pesticides, done. environmental chemicals and cleaning agents. That is where the research is going to be going to. Q127 Countess of Mar: Before I ask my question I Professor Warner: Certainly that is something where should declare my interest because I am not a we need more information, but also we need to think member of the Committee but I am allowed to come about the other pollutants or other factors to which in on it. I am a farmer. I produce raw goats’ milk, people are exposed where maybe there is a bit more which we have quite a lot of custom for, and I also evidence. We know that allergic sensitisation can be have an interest in toxic chemicals arising from increased and the allergic reactions themselves can be organophosphate poisonings from sheep dip. Do you increasing if you have simultaneous exposure with an think that the Government’s and the European allergen and, say, diesel particulates or ozone or Union’s eVorts now to control the proliferation of nitrogen oxides, and so there are air pollutants that chemicals and chemical exposures, and particularly might be adding to the burden and certainly chemicals that are used in domestic situations, are increasing the severity of disease. Pollutants may be worthwhile? I know that there is a lot of research now also contributing to the increasing prevalence as well, which is showing that the placenta is not as protective although the data are a bit more tenuous, I think. of the unborn child as it was thought to be. Do you Professor Sheikh: Can I come back on the raw milk think there might be some connection between the point because there are data now from a number of eVects on the immune system that might have studies which show that raw milk consumption may happened in utero and the subsequent allergies that be protective, including data from the UK which are showing up? That is rather a lot of questions all have recently been published. The point here is that together. now we need prospective work and interventional Dr Devereux: The goats’ milk— work to understand this phenomenon better. One of the issues of relevance is that if we do introduce Q128 Countess of Mar: You need not answer that. legislation around milk or other issues it is important, Dr Devereux: No, no. The work from Switzerland, bearing in mind how little we know about early life Austria and Germany showed that one of the influences, that that work is in an evaluative context. protective eVects of living on a farm was from For example, raw milk sale, as you are no doubt consuming unpasteurised milk before the age of one. aware, is banned in Scotland, so the scope for any Whether you want to advocate that as a widespread interventional work is therefore very limited, but was measure I doubt because of the problem with there any evaluation put into place to look for tuberculosis. unintended consequences which may have resulted from that ban? We need to be thinking much more Q129 Countess of Mar: No, in fact I never broadly. recommend goats’ milk to a child under the age of Dr Devereux: The other thing is that people who one and we know that our goats do not have TB. purchase farm milk, unpasteurised milk, have Dr Devereux: If you put it in context that is quite an diVerent lifestyles from the rest of us and so it may interesting point. There is increasing interest in the not be the milk; it may be some other factor that they possibility of environmental pesticides and things are exposed to or not exposed to. It may be a mark like that. There is this interesting work from various of lifestyle. groups around the world showing that you can detect Countess of Mar: It is quite interesting. Our these chemicals in the blood of newborn babes and customers come from a very wide range and generally the exposure seems to influence the neonatal immune they have children who are allergic to “dairy”, as they system responses. Whether these translate into call it. With my reading, apparently there are two current disease we are not really sure. I did look at diVerent sorts of casein. There is alpha casein and one paper. The problem was that the levels of some beta casein, and I cannot remember which way round science and technology committee: evidence 51
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner it is, but there is one that is found in goats’ milk and contributes. By having energy saving we are creating Guernsey and Jersey cows, and the other is found in tight homes which are increasing the levels of the black and white cows that nearly everybody’s nitrogen oxides and volatile organic compounds milk comes from. It may be that since the fifties which might be contributing to enhancing farmers have tended towards having Holstein herds, sensitisation in the first place. If we are going to have the black and white cows, rather than the Channel tighter housing for energy saving then we need Island cows, and there is a possibility there that it proper ventilation systems with heat exchangers in may have changed the metabolism somehow. The order to achieve benefit for everybody. other one is the altered protein on pasteurisation, where the protein itself is altered on pasteurisation. Q131 Lord Soulsby of SwaVham Prior: It is Cheese-makers know that pasteurised milk does not interesting what you are saying. The question make the same sort of cheese as unpasteurised milk. naturally arises, are the people who are making proposed regulations aware of the dangers of energy Q130 Lord Soulsby of SwaVham Prior: Can we talk saving and things like that? If they are not, how do about housing conditions and poor housing, and you get that information to them? whether that contributes to the burden of allergic Professor Warner: Many years ago, I was involved in disease by way of, for example, increased dust mites, research with the Building Research Establishment, moulds and other environmental bacteria organisms? and at that stage they were very aware and doing If there is anything there, should that danger in quite a lot of work, but the BRE is not now housing accommodation and other buildings be predominantly government-run or sponsored; it is an reflected in the Building Regulations? independent organisation and I am not aware of Professor Burney: Yes, I am sure that is true. I think what they are doing. There are other countries, notably Denmark, that have put quite a lot of work there is quite good evidence that damp housing with V V mould causes problems, particularly for patients with into housing design and its e ect for allergy su erers. asthma. Clearly, that is an avoidable risk that they run. That certainly could be important. We know Q132 Chairman: Can you clarify for me from your that also, for instance, in some places, where you get answer whether you are saying that low-allergen very high build-up of, for instance, oxides of nitrogen housing is actually unlikely to prevent allergy? from gas cooking—particularly with gas stoves— Professor Warner: Based on studies so far done, the that can have an adverse eVect on patients with low-allergen housing is almost certainly not going to asthma. That is quite easily remedied by having prevent allergy because you are not just reducing proper ventilation. I think it goes back to what I was exposure to the allergen. There are other knock-on saying about regulatory bodies always taking eVects of reducing allergen exposure such as reducing account of the fact that a very high proportion of the exposure to bacterial products, which might increase population is allergic, and I think Building allergy risk, with ventilation systems, and reduced Regulations should reflect that. exposure to irritants might reduce allergic Professor Warner: I think it is important, however, to sensitisation. So there is a bit of a balance: some distinguish between housing conditions that may things are perhaps not making any diVerence and contribute to the development of allergy in the first others may actually be having some benefits. Studies place. After all, everybody lived in damp, cold that have looked at, say, reducing house mite housing one hundred years ago and there was much avoidance in early life to prevent disease have shown less allergy, so it is not necessarily increasing the risks that there is a reduced rate of early wheezing illnesses of being allergically sensitised. However, once you not associated with allergy, but later with no are allergic and have a problem there is no doubt that diVerence or, maybe, marginal increases in allergic- living in damp, cold housing makes your problems associated wheezing. worse. For instance, in the United States, the inner city deprived population have infinitely more severe Q133 Viscount Simon: For the last 15 years or so, I and even life-threatening asthma at higher prevalence think it is acknowledged, there has been a year-on- than those living in better housing. So there is year increase in hospital admissions for anaphylaxis, certainly a need to address that, but we need to think which suggests an underlying change in the about whether in changing the indoor environment, epidemiology of this sort of allergic emergency. What this which might increase the risk of allergic can be done to reduce the number of people admitted sensitisation. I know that sounds a paradox but there suVering from anaphylactic shock? are very diVerent influences between creating the Professor Sheikh: You are absolutely right the data problem in the first place and aggravating it once it show very dramatic increases over the last 15 years or has occurred. There is, again, more work to be done so, and these are year-on-year increases, and they to understand the indoor environment and how it continue. There are three issues that need to be 52 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner considered primarily. One is that in those presenting suggests that, particularly in hemodynamically with acute anaphylaxis in hospital accident and compromised individuals, they may be increasing the emergency departments we know that very many of risk of arrhythmias in these patients. They are also these patients are still getting sub-optimal care, so often getting steroids, which, if given intravenously, many of them will still not receive adrenaline, which again, are going to have virtually no impact on the is a potentially life-saving treatment; they will often acute illness. Again, there are no real scientific data get other forms of treatment, in the form of on which to base those treatments, so in such a case antihistamines or steroids, and here there is emerging we need to be rethinking some of these guidelines. I evidence to suggest that we may actually be doing am, together with colleagues in Canada and the US, more harm than good in those cases. One of the involved in those discussions, so I think we will get things we need to be doing is developing a far more progress internationally in the next few years. secure base around how we manage this in an emergency context and seeing if that will improve outcomes. That is challenging to do because this is a Q135 Lord May of Oxford: Under the heading of life-threatening emergency, so it needs an hospital admissions I want to ask a follow-up that appropriate regulatory framework and it needs ethics goes a little wider, although it does relate to this. One of the background papers we were given is a report committees to think more flexibly than they have Y done hitherto. That is one issue. I think the second from the O ce of National Statistics, by the authors issue is about long-term provision for those who have Gupta and Strachan, and it shows that there has been a history of anaphylaxis. We have tended to think a decline in hospital admission rates in relation to about this as an acute problem only, but this asthma among children in the last decade, and it goes condition has life-long implications and multifaceted on to say: “after three decades when prevalence implications. One of the things we could be thinking studies, primary care contacts and hospital about is developing anaphylaxis long-term admission rates all suggested a rise in the burden of management plans, as is now common in some other asthma in children”. They became disassociated in allergic problems, such as asthma or other chronic decade 1990 to 2000 (possibly, it has been suggested, disorders, and that needs to be done, but again within it is just more widespread use of preventers reducing an evaluative context. There needs to appropriate the incidence) but then they go on to say: “At a incentives in place in general practice, but I think regional level in England [and they quote studies] with a will we could probably devise these. That there was a very poor correlation between admission would commit us to identifying the allergens that are rates for asthma [which have gone down] and the responsible for provoking anaphylaxis so patients prevalence of wheeze (even of severe wheeze) [which know how to avoid these products, and also training had gone up] among children, [and here comes the them in appropriate emergency provision if they do question] suggesting that referral and admissions get exposed. Taking that twin-strand approach policies, rather than the incidence of acute attacks, would probably help us in reducing some of this are potentially the important determinants of asthma burden. admission rates”. So I have two questions: the first is—and I imagine you are quite sure but it would do well to aYrm it—that the rise in admission rates for Q134 Chairman: In your response to Viscount anaphylactic shock is real and not a change in policy. Simon you were saying that the current management But then I would like to cheat and ask a second where they are not going to use adrenalin early may question: do you have a comment on the thing I have be doing more harm than good. I wonder if you could just read, which really is quite an important expand on that. statement if true. Professor Sheikh: Certainly. Adrenaline is Dr Devereux: Fundamentally, the person who decides internationally recognised as the treatment of choice whether a patient should go to the hospital is the GP, in anaphylaxis. Unfortunately, very many patients so referral patterns are very important. That is what who present with anaphylaxis still do not receive decides whether a patient gets referred. I personally adrenaline. Having said that, there have been very feel that the reason why admission rates have gone few empirical studies on which to base the decision to down is because GPs are managing asthma much treat with adrenaline, so we do not know the correct better than they used to: the increased use of dose to be using, we do not know what the correct preventative medication, as you have just said, route of administration is, and we do not know when asthma plans at home, patients are basically able to is the appropriate time to give the next dose of take their own steroids when they get symptoms, they adrenaline. So there are massive gaps. What people have peak flow-meters at home, it is far more do get when they walk into an A&E department is controlled and you get fewer patients coming in who antihistamines, and they will be given antihistamines have just acutely deteriorated. Most people are able intravenously, typically. There are some data which to manage it at home and GPs are increasingly science and technology committee: evidence 53
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner confident about their ability to manage asthma at and then extracting some of their individual case home. As you said, they are more confident, the records, subjecting them to a panel of experts and medication and management plan is in place and seeing to what extent the data are valid. That work, fewer people are getting referred. again, is on my agenda—we need to do that. In relation to surveillance, with these numbers and this Q136 Lord May of Oxford: So the severe wheezing rate of increase then surveillance is entirely attacks that previously would have had them appropriate. Our estimates, at the moment, are that admitted are now managed at home. in England there are some 38,000 people (these are Dr Devereux: Yes. unpublished data) who have had a history of anaphylaxis at some point in their lives. These are still relatively small numbers, so a surveillance Q137 Viscount Simon: Following what Professor programme for anaphylaxis could prove feasible. Sheikh was saying, I have two questions: one is Some kind of longitudinal tracking of a sample of personal, I am afraid to say, and the other one is more these individuals would help us to far better to do with this inquiry. You were talking about understand the epidemiology of this condition. I am cetirizine and allied medicines and, also, adrenalin. I part of an international group looking at the take a huge doze of cetirizine every day of the year epidemiology of anaphylaxis, and you are right to and I carry adrenalin with me. From what you are point out there are massive gaps, but in the UK we saying, should I use the adrenalin in an emergency? are probably the most developed in terms of our The second question, which is the general one, is do understanding. you think it would be worthwhile starting or Professor Warner: instituting a national anaphylaxis surveillance May I make some comments? programme? Firstly you are not doing yourself any harm taking Professor Sheikh: Maybe I can try and take both of regular cetirizine and you might actually be helping these questions together. In terms of your personal some of your allergic manifestations, which is rather V question, if you are experiencing symptoms of di erent. In relation to the increasing rates of severe, anaphylaxis then certainly use your adrenalin and get acute allergic reactions, particularly in relation to some help. I think everybody would be in agreement food allergy—clearly there has been a dramatic about that. In relation to hospital admissions, change in people’s eating habits and what kind of hospital admissions are the tip of a clinical iceberg, so foods they are accessing. It would be relatively easy studying those is subject to all sorts of potential to avoid peanuts if everything you ate was cooked variables. However, we are on reasonably firm yourself having bought fresh food in the market and ground, when we have got data pointing in the same from the butcher. Of course, that is not what happens direction irrespective of the data source, as in asthma now and people are buying products that have gone for example—we know that hospital admissions are through a whole series of processes and been declining and we have got a pretty good idea of what manufactured and packaged. Under those is happening in general practice as well—really what circumstances the potential for there to be we are seeing is a decreasing burden, or at least a unexpected peanut within those products, stabilising in the disease burden. In relation to unfortunately, is significant and creating a problem, anaphylaxis, what we are seeing is that hospital and it is a nightmare for suVerers. They now have a admissions are going in a certain direction, very poorer quality of life than someone with diabetes clearly. When we have investigated the possibility of requiring insulin every day. That is now well diagnostic transfer taking place, and it seems that is established. It is a question of, maybe, changing our unlikely to be taking place, we have looked for eating habits and raising awareness that ought to, in regional diVerences and it seems, again, that there are the end, have an impact. Yes, we have to understand similar patterns all across England. We have looked why the whole problem has increased but, at the same across diVerent age groups and, again, it seems that time, to help people that are suVering now I think there are similar patterns in most age groups. In there are things we can do. terms of primary care data, which are as yet Professor Sheikh: The degree of distress that some unpublished but hopefully will be within the next few young people experience by being confronted with months (once I have finished with this I can get back labels saying “may contain traces of nut” is to writing the paper), what we see there is that there something I think we underestimate. Let us turn that is improved diagnosis taking place in general practice on its head. I think there is a market now for products but, over and above that, there is an increased which are guaranteed to be nut-free and similar other number of people with anaphylaxis. Failing that, the products which are guaranteed dairy-free, for only next step that remains in unpicking this jigsaw example. Some work needs to be done to look at that is going back and doing some validational work, so and that would, again, be something that would be looking at people who are admitted with anaphylaxis very useful to a lot of people. 54 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner
Chairman: We have quite a lot of questions still and multifaceted interactions may be particularly I am aware of the time, so I think we are all going to promising. try to be concise with our questions and appreciate if you could with your answers. It would be really Q142 Baroness Platt of Writtle: Are grant funding important to get through questions on primary bodies distributing money for research into allergic prevention and research. diseases in the most promising areas? Could we be getting better value for money from investment in Q138 Lord Taverne: Turning to research, in an area research? In two lots of evidence we have had, where there is so much uncertainty, what are the most including Professor Warner’s, there is a promising areas of research into primary prevention? recommendation for a central funding body. I am What would be likely to produce best value for slightly nervous about that as it might be money? For example, would it be diets of pregnant bureaucratic, but perhaps you might like to refer to mothers, pre-biotics, pro-biotics? What is your view? that in answering. Dr Devereux: I am very biased. I think there is Professor Warner: At the moment, most funding for increasing evidence that we should look at maternal allergy research is handed out on the basis of diet during pregnancy. I am being encouraged by judgments about what is the best scientific proposal, various people to actually go ahead and try and do an and therefore there is not any strategy behind that; it intervention study. Whether I get funding for it or depends on the individuals submitting from an area not—it is clearly going to be a hell of a job to get that they wish to investigate rather than one which funding. Pre-biotics certainly. If you speak to the necessarily might be, in the end, the best thing to do people who make pro-biotics, they think the case is from a public health perspective. My suggestion was made, with a couple of well-designed intervention maybe one should think about having some kind of studies in pregnant women showing a reduction in co-ordination identifying target areas for research. I eczema with pro-biotics. So I am biased, and that is do not mean being intensely bureaucratic but just my biased view. I would go for maternal diet, but I inviting people to apply in target areas that are seen am sure other people will go for other things. to be important from a public health perspective. Professor Warner: I would agree. I would put diet as Dr Devereux: The Food Standards Agency (?) did put number one, although I prefer to call it nutrition out a call for studies of early life diet and respiratory rather than diet because it is nutritional enhancement outcomes in children, and we thought we were in a rather than avoidance. After that I would still focus good position to get this because we are probably on pre-biotics, not pro-biotics—I do not think the leading the community in doing this sort of research, case has been made for pro-biotics. I think the but we were turned down on some fairly weak sort of interactions of all the diVerent organisms in the gut grounds. I have been banging my head against a brick are very complex but pre-biotics look more wall for the past few years trying to get money to fund promising. After that it is some form of immune study into nutrition and asthma, and I have a real modulation using other microbial agents to induce an headache now after banging my head against a brick appropriate immune response. Those are the three wall for so long. areas I would focus on. Q143 Lord May of Oxford: It might be helpful, just Q139 Chairman: I wonder, too, what you feel about quickly, to clarify. The Medical Research Council, in V maternal smoking and the e ect of maternal smoking particular, has three categories of grant: one is the on the risks of a child developing allergy. responsive mode, as you have just suggested; at the Dr Devereux: It is well known and accepted; it is well other extreme are occasional things where they do documented and I think everybody accepts that. pick out an area and, I think, very interestingly, in between them is this third category of highlighting an Q140 Chairman: There is no controversy about it. area, where they do not exactly set aside a pot but Dr Devereux: No. they say: “Here is something where we think perhaps it might be useful if you could start lobbying”. Q141 Chairman: I am really glad to have that on Dr Devereux: I have been told that in the next year or the record. so respiratory medicine will go up the list of Professor Sheikh: I agree with the points made, but the competing priorities, but I will wait and see what other area is that when we have so many potential happens. risk factors we need to be thinking more about Professor Sheikh: One of the problems here is that we multifaceted interventions in early life. So this may do not have a level playing field in that we do not have involve a combination of immune modulating a major allergy charity that the academic community treatment and allergen avoidance, for example. can turn to. Allergy UK and Anaphylaxis Campaign There are some data which suggests that these have no money for research, unlike the Cancer science and technology committee: evidence 55
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner
Research UK or Macmillan, for example. In the epidemiologist to tell you there is a problem, you just absence of dedicated charities, some kind of central go into the casualty departments and they are filling highlighting of the need for dedicated research up with asthmatic patients. We know that this has funding and a dedicated pot for the important happened, also, with castor bean from processing translational health services research really needs to places. We don’t know whether this happens on a be done. We are not in a position to answer hardly smaller scale. So it is really speculation. We know any of these questions that you have posed, that there are conditions under which this can unfortunately, because there is nowhere to go to get happen, and I think it is an area we need to know a any substantial money to do this kind of work. In lot more about. We need to know what allergens can terms of primary prevention, we need long-term cause such problems and we want to know, really, follow-up; we need 15–20 year studies. The Scottish whether they are controllable. If they come from an Executive have not, for example, prioritised this and industrial source they are probably controllable; if they have got a ceiling on project grants of £150,0001. they are natural allergens there is probably not a lot There is no way you can do this kind of work on that you can do about them. kind of money. Q145 Lord Colwyn: It is advantageous to live in Q144 Lord Colwyn: This is a question that comes areas of non-pollution. from the helpful paper from Professor Burney and Professor Burney: Yes, in a way, but it is a diVerent the outdoor environment. I wonder whether you kind of pollution. could make any further comments on your statement: “there is a continuous low level of eVects Q146 Lord Colwyn: One other thing is a subject I from allergens in air, but the nature of these . . . is have spoken about in the House of Lords, probably uncertain.” Then you say that some of them are likely for 25 years now. Have you anything you can to come from man-made sources and need further comment on in relation to electromagnetic pollution? investigation. Can you follow up on that at all? Professor Burney: No, not in this context. Professor Burney: The evidence so far is in rather Y general terms. The di culty is that an allergen is very Q147 Lord May of Oxford: I think probably the specific to a particular person. There are things that most useful thing I did while I was the Chief Scientific V are commonly allergic to many di erent people, but OYcer was promulgate rules for handling science everybody has their own allergens. So it is quite a advice in policy making and giving advice to the Y di cult area to study in that way; it is not like public, but these things are much more easily said studying air pollution from, let us say, nitrogen than done. This is a very good example, it seems to dioxide, which is something you can measure and it me, where, as we have heard, there are so many of the is the same for everyone. What we know now is that issues where there are various ideas and conflicting allergens in air do cause exacerbations, and we can evidence. How do you see, against that background, say that it is an allergen but we do not necessarily in this particular instance, formulating the advice we know what the allergens are. The other part of your give to the public—guidance? question is something we can speculate on. We know Professor Sheikh: One of the issues we can do is we can it is very likely, for instance, that moulds in the advise which interventions are not working, and that atmosphere are part of the problem—I cannot tell can be useful advice. For example, taking measures you exactly how much of the problem—but the other to avoid aero-allergen exposure domestically is very thing that we know, from rather spectacular unlikely to prevent allergic disease. A number of epidemics that have happened, is that these can occur people are doing this with no clear evidence base. In because people are storing and releasing large terms of the positive recommendations that we can quantities of allergen. So, for instance, one of the make, I think we need to appreciate that we are at a more recent epidemics happened in the 1980s in very early stage in this story. Overall, advice has to be Barcelona where they were storing soya beans in silos evidence based and this evidence will accrue. If you in the dock. The silos were uncovered, so when they can help in allowing us to do the research in any way dumped large quantities of soya bean in they released then certainly we can feed into that process. soya bean allergen into the air. Under the wrong Professor Warner: I have had my fingers burnt over atmospheric conditions in which the soya bean was this. I was on the Committee in the Department of spread around the town you got really serious Health that made the suggestion that in families that epidemics. So we know that there are sources of have allergies it would be sensible for mothers to allergen. Such events are quite rare but in order to avoid eating peanuts and tree-nuts and not giving find them you have to have these big epidemics, and them to their babies for the first three years of life. then they are obvious; you do not need an That advice still stands, but evidence is now accruing 1 This has since been increased to £225,000 which suggests that that might not just be having no 56 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner eVect but it might actually be having the opposite Q151 Lord May of Oxford: I would gratuitously add eVect. So although it was made in good faith at the that the guidelines on science advice say: “If you are time, based on evidence available, it was indirect not sure you say you are not sure”. My personal evidence rather than direct evidence. Perhaps we belief is, as you said, it is confidence enhancing. have to be very cautious about any recommendations Dr Devereux: It works with patients when you do not we make until we have got good evidence from know what is wrong with them and you tell them you controlled intervention rather than just do not know. observational studies.
Q152 Lord Rea: We move on to another wide area Q148 Lord May of Oxford: Can I ask a follow-up, which is the association between diet and allergic mounting another of my hobby horses? I am very diseases. I found Dr Devereux’s review article that we down on the wasteful and energy-consuming over- were circulated with extremely useful in this area, packaging of food in supermarkets, and so may I ask particularly with regard to the diet of the pregnant you if there is any reliable evidence to show that woman and the eVect on the foetus and the preservatives used in plastic food packaging increases subsequent child. Could you develop this theme? the risk of allergic diseases? If so, should the public be Dr Devereux: We have been conducting a study for advised of this? the last four or five years where we recruited a large Dr Devereux: There are some preservatives that will number of women up in Aberdeen, looked at what exacerbate your asthma. There are some, like they ate during pregnancy and then have been tartrazine and metabisulphite, which will exacerbate following their children up. We have done it for five your asthma and make it worse, but whether they years so far and have been able to show that in actually cause asthma is a diVerent matter. mothers who had a low vitamin E intake it aVects the core blood immune responses, it aVects their Q149 Chairman: Did you want to make a comment, children’s wheezing outcomes at the age of 2 and it Professor Warner? aVects outcomes at the age of 5. You have got Professor Warner: No, we just do not know, really. objective associations with things like lung function Lord May of Oxford: If you were to oVer such advice measurements and we have got associations with you have to say you cannot be sure. measures of airway inflammation. These have been repeated by an American study very much along similar lines, called Project Viva in Massachusetts, Q150 Lord Haskel: Would you advise that we which is showing very similar associations with should inform the public that we do not know an awful lot about this, or do you think that is very vitamin E and core blood responses and wheezing at dangerous? the age of 2. We have also more recently looked at the Professor Warner: I do not think it is dangerous. data showing associations between zinc and vitamin There is a great tendency for people to think that D. Vitamin D is particularly interesting because there there should be an absolute answer, and yet actually is this latitudinal association with asthma. If you look I think the public are perfectly capable of at the map of where asthma prevalence is high it tends understanding when we do not know and therefore to be the extreme northern and southern cannot make a recommendation. hemispheres. Vitamin D intake has gone down, and Professor Burney: I think the real danger is in coming vitamin D has some very interesting properties on the out with these pronouncements based on indirect immune system. So what we are coming up with is evidence. A lot of these hypotheses are very early evidence to suggest there is an association. intriguing, they catch the imagination, and we want There is not enough to make a recommendation yet them to be true because they are rather beautiful but it is probably enough for us to want to go ahead ideas, and we are in danger of going beyond the and do an intervention study to see whether evidence. Then we give advice and people are intervening has an eVect and whether it is practical to disappointed; they say: “You told us one thing last intervene during pregnancy, and whether pregnant year, it is a diVerent thing this year”, and I think we women would be willing to change their diet in order lose credibility. The public can tolerate ignorance. to prevent their children developing asthma. We have That is not to say that we cannot find an answer, but looked at the magnitude of the eVect and we have it will take time. worked out that if we could get pregnant mothers to Professor Sheikh: Ideally we would like to see increase their vitamin E intake during pregnancy newborns in very large numbers entering into the from what it is now to what it was in 1950 you would trials that are so urgently needed. So any advice that halve the prevalence of childhood asthma at the age you can give to say that we do not know would be of 5. Those are big claims and it needs to be backed very helpful. up with some intervention. science and technology committee: evidence 57
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner
Q153 Lord Rea: You said earlier that you were Lord Rea: Thank you very much for making that searching for funding to do an intervention study point. like this. Dr Devereux: I would like to, yes. Q156 Chairman: Can I ask you, Dr Devereux, in relation to food, is there any evidence of a diVerence in, particular vitamin E which you have been talking Q154 Lord Rea: Would this have to involve big about, in its content between locally produced and numbers? Is that why it is going to be diYcult to get locally ripened fruit and vegetables versus those the funding? which are imported, picked relatively unripe and Dr Devereux: The numbers are going to be about artificially ripened and transported large distances? 1,000, I think. The problem is (a) getting somebody Dr Devereux: I am not aware of any data for vitamin interested in a nutritional theme—there have been E but there are one or two very obscure papers that lots of studies looking at giving antioxidants, like big, purport to show that with food that is transported a big doses of vitamin C, to prevent cancer and heart lot and is old, the vitamin C content goes down in disease and they have all turned out to be ineVective pineapples, and also in food grown out of season in if not detrimental, whereas we are thinking along a poly-tunnels the flavonoid content is meant to be diVerent line here; we are thinking of small doses of altered as well. These are pretty obscure, German- vitamin E, maybe changing diet rather than giving a type, papers which you have to get translated, but it supplement—and (b) the duration. You are going to is not very strong data. However, common sense have to recruit pregnant women during pregnancy, would tell you that the diet we are eating nowadays is intervene and follow the children up for at least five diVerent to what we were eating during the war, and years, and that is a big study; it takes a lot of money just after the war. to do that sort of study. So it is a question of funding bodies’ interest and funding—the actual cost. Q157 Viscount Simon: Can vaccines and drugs be used to prevent as well as treat allergic diseases? If Q155 Lord Rea: We have discussed on a number of they can, what sort of advantages or disadvantages occasions the role of pre-biotics and pro-biotics. Do does this approach have compared to dietary you think if pregnant women take these it is worth manipulation? looking to see what the result is, and is there any Dr Devereux: I would point out that 100 years ago we evidence that there is any benefit? were not vaccinating children against allergic disease. Professor Warner: There is for pro-biotics at the Also, as a father, if I had a choice between getting my moment. The pre-biotic work is only in progress at wife to eat a diet which was healthy and having my the moment. The studies have tended to give the pro- child vaccinated, I would go for getting my wife to eat biotics to the mothers in the last month of pregnancy healthily. There are also the concerns that you are and then also to the babies for the first few months of doing something to a newborn child, and there have life if they are being bottle-fed rather than breast-fed. been scenarios explained here today where allergen So we do not know whether it is an ante-natal eVect avoidance has given you exactly the opposite to what or a post-natal eVect, or both. The diYculty is if you you expect. We have to be certain that any proposed have the kind of studies that Dr Devereux is vaccination schedule doesn’t have the opposite eVect proposing funding, say, for two or three years— to what we want. So you have to be very careful about which is what tends to happen—and then he goes using vaccination as a primary prevention. back in two or three years to say: “Now can we sustain the follow-up, and give me the extension Q158 Lord Rea: There is, surely, a case for de- funding to get it through to five and six years of age sensitisation in cases where anaphylaxis is the when we can be more certain about the diagnosis of problem. I know personally, because I had an asthma?” the grant-giving bodies turn round and say: anaphylactic reaction to a wasp sting and the “What is your hypothesis?” You say: “It is to carry Brompton Hospital very nicely de-sensitised me. Of on what we were previously doing”, but they may course, I do have an EpiPen but I have not ever had well come back and say: “The situation has changed to use it. Other than wasp stings, are there not several now; we are working on a whole new area; we are no allergens that it is worth de-sensitising from? longer interested in this any more.” That study loses Professor Warner: Yes, indeed. There is good evidence any opportunity to derive meaningful information that house mite vaccines, pollen vaccines and because of that. I think that is something that many vaccines against cat and dog will have benefits in people suVer from—not being able to sustain cohorts people who are already allergic. So as a treatment, for long enough to get the proper results at the end. yes. The issue for this country and a number of others There is a large number of studies that have faltered is generating vaccines that are safe and are not going because of that in recent years. to cause adverse reactions whilst they are being 58 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner administered; there is the potential for them to cause Professor Warner: All one can say is that we have to an anaphylactic reaction as they are being work with evidence. We have talked all along about administered. The new developments are to find safe evidence, and the issue is, have these therapies vaccines to generate components of the proteins that undergone suYcient scrutiny with proper controlled will immunise without causing an allergic reaction. I studies to demonstrate that they have an eVect? The am sure that is going to come. There are some very answer is, for the vast majority, they have not. That exciting developments in that area. The other thing is does not mean we are closing our minds to the whether these vaccines might have a role somewhere potential for them to have some benefits, but I think earlier in the process. There is evidence from a trial it is incumbent on the people who recommend them conducted around Europe of giving pollen vaccines to do good studies to demonstrate that they are to children who had just allergic rhinitis but not yet eVective. That is the treatment side. I can say very asthma, which showed that less asthma developed in emphatically on the diagnosis side—that is, where the children that received the vaccines compared with complementary practice is trying to diagnose those that did not but had similar allergies. There is allergy—it is utterly and totally without any potential for looking at it in an earlier stage in the validity, and in many cases has been shown to be evolution of disease but I think we would have to be totally bogus. very cautious about starting in the newborn baby. This is in children who have already showed the first Q161 Lord Colwyn: I will not take that up with you signs of allergy, where it looks as if this might change now, but I disagree with that. the longer-term outcomes in a way that no other Professor Sheikh: I will not answer yes or no, but in pharmacotherapy has been shown to be able to do. relation to your question about preventing allergic disorders I think the answer is we do not know Q159 Viscount Simon: Would a strong family because the studies have not yet been done. history, perhaps, be suYcient? Professor Warner: One of the things that a colleague of ours in Swansea has wanted to do is look at early Q162 Countess of Mar: Do they not have exactly BCG vaccine in a trial in babies born into allergic the same problem as you have, in that they cannot families, to see whether that would reduce outcomes get funding to do the studies? in relation to allergy. He has applied repeatedly for Professor Warner: That is true. money to support that study and it has never been Dr Devereux: Yes, exactly. supported. I think the state of knowledge has moved Chairman: I do not know if anyone on the on now and there is, perhaps, less evidence to support Committee has any other questions they would like him doing that than there was five years ago, but to put to our panel. people have tried to suggest these sorts of studies and, hitherto, have not been supported. There is one study Q163 Lord Rea: On nutrition, we should perhaps just about to start which is being funded from the discuss the role of breastfeeding and weaning United States—Professor Gideon Lack to do a study patterns: whether partial breastfeeding or total of administering peanuts in very young children who breastfeeding is best and what should be advocated. are just showing the first signs of allergy. These are in Professor Warner: It is a very diYcult area. There is very small babies who are beginning to show eczema no doubt that exclusive breastfeeding for at least the but are not peanut-allergic, and giving them large first four months of life reduces the rates of early doses of peanuts in a controlled trial. So these sorts food allergy and eczema. There is rather less of studies are being thought about and are just evidence that it has longer-term eVects on the later beginning. allergic manifestations, but there is no doubt about those early ones. How long should breastfeeding go Q160 Lord Colwyn: Do you think that on, should it be partial, how rapidly should weaning complementary and alternative medicine has a role occur—I think we just do not know. There is a to play in the prevention of allergic disease? I am current recommendation in many countries that in not going to allow any of you to say yes or no on allergic families weaning should be slow, with a that; I want to widen it a little bit. In my view, particular delay in the introduction of the allergenic complementary and alternative medicine is about foods. Actually, what evidence is now accumulating immune system enhancing. To my mind, that would suggest that that is totally wrong and that it includes nutritional supplements, which Dr is better to wean early on to allergenic foods and to Devereux has talked about already, herbal diversify the diet quickly, and it may even be better medicines, ayurvedic medicines and, of course, the to do so while breastfeeding continues because there anti-stressors—chiropractic, osteopathic and might be factors in the breast milk which might help acupuncture. Take it from there. modulate the response to the foods as they are science and technology committee: evidence 59
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner introduced. Again, research is required in order to Q165 Chairman: Thank you. Do you have establish what really is the best recommendation. comments you would like to make? Professor Burney: May I make one comment which thoroughly supports that? I have sat on some Q164 Lord Colwyn: Introduce nuts and things in funding committees and been faced with exactly that very, very tiny doses as early on as possible? dilemma: that you have got some very good, very Professor Warner: Yes, perhaps. The research needs precise basic science that comes through that you to be done. I am not recommending it now. know is going to find the exact answer, because if Professor Sheikh: In relation to the delayed weaning the lab is half good it will have no diYculty with issue that has been advocated in the past, again, the experiment, and you know it is a very good lab. there has really been no firm evidence underpinning Against that, you have got a more speculative bit of this, and currently with a three-month-old born into work that is going to advance general knowledge a high-risk allergic family at home, who is screaming but is not going to give you the same kind of precise at night because he is hungry, we are not following answer. It is a dilemma for the funders; I think we that guidance. have to recognise that. The other thing, going back Lord May of Oxford: I thought this was a super to your original question, is that the National session and I would like to go back very quickly to Asthma Campaign has actually put quite a lot of Lady Platt’s question about funding. I share your eVort into reviewing the areas that are important, reservations about wanting to direct things, but and they have brought out regular documents nonetheless I think our discussion has implications, saying what areas they think are most ripe for maybe, for some of our later sessions. It seems to exploitation. I think they have done that with the me there is a more general thing. The MRC does Department of Health. The real problem is the total fund this work, the Wellcome Trust does fund this amount of funding in the area, and I think most of sort of work, but nonetheless I think it fair to say the evidence is that funding in the area of there is an understandable prejudice to want to do respiratory disease and this kind of allergy (not the “high-techy, moleculary” things. I am always high-tech immunology) is very low compared with mindful of the dictum of Tukey—possibly the most other similar conditions. distinguished statistician of his generation—who Professor Sheikh: One of the issues is that when you said: “Far better a rough answer to an important have relatively small pots of money for allergy what question than an exact answer to an unimportant it can do is promote quite a lot of rivalry between question”. I am not sure even if all the Committee groups. When you are vying against other disease quite realise that in the subject of immunology we areas, if there is that internal rivalry you are actually have an unbelievably brilliant understanding of shooting yourself in the foot quite a lot of the time. how—at the individual, molecular and virus level. If in your recommendations you can think of any Take HIV. We now have the individual HIV virus ways of promoting more collaborative research— interacting with the individual immune system cell, because some of these studies we are talking about and on that basis we can design anti-retrovirals to will need very large numbers; they will need a keep people alive, but we still have no agreed collaborative ethos—and you can give some explanation for the pathogenesis of HIV. Most of suggestions along those lines that would be very the people working in the area somehow do not even welcome. realise that. It requires your understanding of many, many diVerent viral strains interacting. It is a very complicated kind of question. I suspect, as we said Q166 Chairman: You lead me into a question I have, earlier, the immune system is not programmed in which will be our last question this morning. You did our genes; it assembles itself, largely, in the first few speak earlier on about the charitable organisations years of life. Common sense suggests there are that do not have research funding. I wonder whether hugely important things to be done in they do not fund research partly because they do not understanding the interplay between these many feel confident in sorting out who to fund and partly things we have talked about, yet the kind of because they feel that somehow patient information proposal you are going to put forward is not going leaflets, and so on, are more important. Do you feel to be a piece of precise, physics-like (for people who that some of those charities should be encouraged to do not understand physics but think what physics is be specifically fundraising towards an aggregated like) thing that finds favour. I would hope we might research pot over and above the pots that already keep that in mind for some of the subsequent exist? sessions because it is perfectly clear that I am going Professor Sheikh: I would certainly encourage that. to come back to this when we start saying our One of the things we have had in respiratory medicine recommendations. I thought it helpful to say it now. recently is the formation of a national respiratory 60 science and technology committee: evidence
6 December 2006 Professor Peter Burney, Professor Aziz Sheikh, Dr Graham Devereux and Professor John Warner research strategy committee which is bringing of that, but actually the environment for raising together diVerent funders—government and funds from charitable sources is very diVerent to charitable. Something similar in the allergy field what it was 10 or 20 years ago. It really is quite would be a very useful way forward. Maybe I could diYcult for them to get funds these days. ask John, because you sit on the Anaphylaxis Professor Sheikh: I have got two proposals with the Campaign as a trustee, I think. Anaphylaxis Campaign at the moment, trying to get Professor Warner: Yes, I am a trustee of the some money to do work, but there is not any, Anaphylaxis campaign, and they have relatively unfortunately. limited resource. Rightly, because the campaign was Chairman: Can I thank you for coming and giving us established by families and patients with severe, acute evidence today. If there is additional information allergy, the first eVort is devoted towards helping that you would like the Committee to know about, people here and now with appropriate support and that you think about when you go away, please do advice. As the funds increase then they have to move send them in and we will circulate them to the into supporting research. I think they are very aware Committee. Thank you all very much indeed.
Supplementary letter from Professor Peter Burney, Professor of Respiratory Epidemiology and Public Health, Imperial College, London I promised a further brief note on the current problems of undertaking epidemiological research. The principal diYculty is in accessing good representative samples of the population at reasonable cost. Previously this was possible by accessing the names and addresses of people registered with general practices. A computerised list of these was kept together with sex and date of birth by the health authorities and age- sex-specific samples could be drawn by post code. No clinical information was kept on these files. Other sources such as electoral lists were more limited and less complete and are even more so now. Although use of these data was acceptable to the public, the data are now regarded as not only confidential but also “sensitive” and access is denied. The nearest alternative now is to approach individual General Practices and invite their collaboration. The first diYculties with this approach are: 1. General practices that refuse (for many diVerent reasons) are not the same as those who do not and so samples are often unrepresentative. Particularly in research into health care this can be a fatal problem. 2. Even if it were possible, it is far too expensive in time and resources to approach all GPs and get small samples of patients from each. Studies therefore need to be of a “clustered” design and this leads to loss of power, or the need for larger more costly studies. However, even if general practices are in principle willing to help they are very often unable to. Under the current arrangements they have to write to their patients to ask whether they are willing to participate and this involves 1) drawing an appropriate sample (which they are generally not qualified to do), 2) printing out the letters and posting them (a process that requires not only time but space), 3) marking oV those who have replied and 4) sending reminders to those who have not. Under the current rules, because we cannot have access to the names and addresses until the patients have replied to say that they are willing to participate, we are unable to help with any of this process. For a busy general practice this is all but an impossible task and it is amazing that we have any volunteers. In addition we have none of the valuable information about the age, gender and postcode of the non-respondents. In all of this I see a large scale repeat of the legal nonsense that held up anonymous testing for HIV and any chance of understanding the spread of AIDS in the UK for some years. What we need is permission to use the names and addresses of patients registered with GPs together with their dates of birth and gender providing: 1. The programme of work, including the letter of invitation to participate and questionnaire, has ethical committee approval. 2. The staV are adequately trained and have honorary contracts with a health authority or trust. PIAG was asked to allow us to take on some of this work for a particular project either outside the surgeries or sending our staV into the surgeries to help. This would have been only a partial solution at best but was turned down on the grounds that the study was “too small” to warrant an exception. That is a judgement that science and technology committee: evidence 61 in my view PIAG was not qualified to make. The relevant perception of the size of the problem is that of the general practitioners and they certainly saw the problem as one that made their participation impossible. Further absurdities are also now creeping into the research governance. Recent advice to us about a questionnaire survey included an injunction to send a separate consent form with the questionnaire and a separate letter and “patient information sheet”. These may seem simple requirements, but there is a world of diVerence between sending a two page questionnaire with a letter giving a brief explanation and asking the recipient to fill it in return it, and sending a legal document with an extensive “information sheet” with what many of the public would see as “small print” and asking them to “sign” that they have agreed to the “small print”. The upshot of all this is that we are organising a European wide survey of allergic conditions this summer and may well not be able to comply with the survey design ourselves. The irony is that a properly designed and well vetted study to improve our knowledge of public health is forbidden, but any company can ring me up at home and conduct surveys or try and sell me whatever they please. If your committee were able to find a solution, this would be greatly and widely welcomed. 10 January 2007 62 allergy: evidence
MONDAY 18 DECEMBER 2006
Present Colwyn, L Rea, L Finlay of Llandaff, B Selborne, E (Chairman) Simon, V Perry of Southwark, B Soulsby of Swaffham Prior, L Platt of Writtle, B Taverne, L
Letter from the British Society for Allergy & Clinical Immunology The British Society of Allergy and Clinical Immunology is a nonprofits professional organisation that has 450 members. The society’s aims are to support its membership in providing a high quality, NHS based service for the treatment of people with allergic diseases. Research is a core value of our society. Many of our members are engaged in research into the causes of allergic diseases and understanding the underlying mechanisms, in order to identify and develop potential novel therapies. Other research interests include primary and secondary prevention of allergic diseases through allergen avoidance strategies, dietary modification and development of novel vaccines to modify the course of allergic diseases. In response to your “Call for Evidence: Allergy”, the BSACI held a “Think Tank”, chaired by Professor Tak H Lee, on 30 September 2006, in order to address research priorities in Allergy. The attached suggestions are representative of allergists, clinical immunologists, paediatricians, rhinologists, chest physicians and colleagues from primary care, from a wide geographic distribution within the UK. BSACI is a small society and unable to fund research directly, whereas the society could and should facilitate a network of NHS-based research centres to support DH initiatives for research in allergy. However, without capacity building within NHS-led allergy services and without a critical mass of well-phenotyped NHS patients there can be no eVective research into prevention or treatment of allergic diseases, or research into optimal NHS care pathways (at both primary and secondary care level). In this regard, the recently published Department of Health Review of Allergy Services gives no cause for optimism.
APPENDIX
Research priorities for prevention, treatment and improved service delivery for allergic diseases The following BSACI members contributed to the list of research priorities:
Dr C Brightling, Dr A Clark, Dr C Corrigan, Professor S Durham, Professor A Frew, Dr R Gore, Dr Y Karim, Professor T H Lee, Dr S Nasser, Professor DS Robinson, Dr G Scadding, Dr A Simpson and Dr S Walker.
1. Identification of Provoking Causes
Genes
Many genetic polymorphisms have been identified that are associated with allergy, but these do not necessarily translate into allergic disease. Additional genetic factors contribute to organ specific allergy, for example, independent genes for asthma risk. Studies must identify how these interact with other genetic factors and the environment, in populations that are well characterised phenotypically. allergy: evidence 63
18 December 2006
Intrauterine environment Further study is required of the influence of maternal health, nutrition, environmental exposure, pregnancy related factors, eg placental function, and genetic diversity on the development of allergy in the oVspring.
Postnatal environment Research should focus on nutrition and exposure to allergens, infection, and pollutants in infancy. The hygiene hypothesis proposes allergy risk is influenced by early life exposure to infectious agents. The timing of exposure, nature of the agents, how they interact with the immune system and host genetic variability is unclear. Data suggest that the dose and route of allergen exposure, amongst other factors such as genetic predisposition are important in determining oVsprings’ allergic risk. Studies have been limited by small numbers of subject studied and heterogeneous populations. The lack of definitive conclusions have prevented clinicians from providing eVective public health advice on allergy reduction measures or identifying high risk individuals. Identification and characterisation of genetic, environmental and gene by environment interactions in early life which provoke or protect against allergy will require study of large birth cohorts. This is urgently required to identify susceptible individuals in whom cost-eVective public health interventions may reduce the allergy burden.
2. Measurement of Provoking Factors (Indoor,Outdoor Aeroallergens and Pollutants) Acute episodes of rhinitis and asthma can be caused by exposure to inhalant allergens (eg pollen, dust mite, animal dander etc). Prior exposure to air pollutants such as ozone, nitrogen oxides or fine particulate matter (PM) reduces the threshold for response and at higher levels, can trigger attacks of asthma in its own right. There is some evidence that exposure to PM (especially PM from diesel exhaust) can drive the immune response toward making allergic-type antibodies (IgE). Measuring environmental levels of allergens and pollutants is diYcult. Most allergens are contained on or within small particles, which vary in their biological impact depending on where they impact (in the nose, the lung or both). Particle size is a critical issue, as only particles with specific aerodynamic properties will impact in any given area. Studies of the eVects of allergen exposure on disease severity must take into account the level of personal exposure, but current methods often rely on fixed samplers, which are aVected by disturbance of the air, the movement of pets around the house, changes of bedding, or fluctuations in humidity and temperature, all of which will cause variation in the measurement of allergen concentrations, and may not reflect to true allergen burden experienced by the patient. Some newer methods are being developed to measure smaller numbers of particles in air as it is breathed in. However, much work remains to be done to validate these tools and apply them to individuals going about a range of representative daily tasks. We also need exposure information for other allergens which may be important, but about which little is known (eg mould and fungal allergens) and on the eVects of allergen transfer from one place to another. Once epidemiological surveys have identified possible triggers and interactions, these will need to be explored in mechanistic studies work to provide a plausible biological explanation for any observations made in survey work.
3. Interventional Studies:Primary Prevention Clinicians and researchers have been designing studies to prevent the development of asthma and allergies for many years—so called primary prevention studies, which start at or before birth. Ideas for prevention strategies come from observational studies of (modifiable) risk factors for the development of asthma and allergies. For example, having an allergy to house dust mite is a major risk factor for asthma as is having parents with asthma. There is nothing that can be done about the latter, but it is possible (although diYcult) to design changes to the home to reduce exposure to house dust mite. There are six ongoing studies around the world that have looked at modifying the home environment to reduce exposure to mite allergens in children at high risk because of parental disease. However these studies have produced mixed and, at times, confusing results and based on current evidence it is not possible to recommend a single strategy for prevention or to define a clear public health message. What is emerging from current observational studies is that to understand the development of asthma and allergies, one needs to study both the genes and the environment and look for interactions. Future primary prevention studies will likely assign risk based on genotype and target the intervention accordingly. It is likely as a consequence of such studies that public health messages will emerge. 64 allergy: evidence
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4. Interventional Studies:Secondary Prevention Sensitisation to allergens (such as house dust mite, cat and dog) is associated with asthma and exposure to allergens in those asthmatics who are sensitised is associated with more severe symptoms. Investigators have therefore studied the eVect of changing the environment to reduce exposure to allergens on the severity of asthma—so called secondary prevention. Although some studies in children have shown a benefit, studies in adults have generally been too small or have been aimed at practical approaches such as changing only 1 facet of the environment (eg fitting mite proof encasings) and have shown no benefit. There is an urgent need for a large adequately powered study of a multifaceted intervention in adults to definitively examine the eVect of a comprehensive mite avoidance program on asthma control in adults.
5. Prevention of Occupational Allergies and Asthma Asthma and allergic dermatitis arising as a direct consequence of exposures in the workplace are common in UK industry; for example approximately 10 per cent of UK supermarket bakers (a workforce of around 8,000) have bakers’ asthma and a similar proportion of those engaged in pharmaceutical research develop an allergy to laboratory animals. A recent report by the HSE estimates that the total lifetime costs to society of the c 600 cases of occupational asthma reported each year range from £71.7 to £100.1 million; since recognised cases are believed to represent only a third of the true incidence, the real costs could be as high as £133.5 million (http://www.hse.gov.uk/RESEARCH/rrpdf/rr474.pdf). The pattern of these cost burdens suggests that employers are imposing a large “external” cost on the rest of society. There are in addition high individual “costs” of occupational disease including, frequently, unemployment and reduction in income. The causes of these diseases are, by and large, well understood and experience in a small number of settings (eg latex in NHS workplaces) suggests that, with suYcient and appropriate eVort, primary preventive interventions are feasible. Extending the breach in this “application gap” will require close collaboration between industry, occupational health and safety services (where these exist) and clinical researchers. This at present can be very diYcult to achieve; and is increasingly so given that there is now virtually no available external funding for such work. This clearly represents an urgent unmet need.
6. Inflammation and Remodelling Research into basic mechanisms of rhinitis and asthma, much of which has been pioneered in the UK, has led to the identification of potential therapeutic targets for intervention and the development of several novel and eVective therapies that include anti-IgE monoclonal antibody (Omalizumab), anti-leukotrienes and the testing and introduction of known immunomodulatory treatments in asthma including Cyclosporin A and anti TNF- alpha. The role of aberrant repair and remodelling processes in the progression of asthma is increasingly recognised. There is an urgent need to address why some atopic (skin test positive) individuals develop asthma whereas others do not. It is also important to understand the diVerences between mild and moderate-severe asthma, the similarities and diVerences between childhood and adult asthma and why some asthmatics progress to severe, progressive and ultimately irreversible disease whereas others do not. These questions may only be addressed through multi-centre studies with adequate funding for research clinicians and scientists working in collaboration and with access to well-characterised patients via adequately resourced NHS allergy clinics.
7. Immunomodulation and Immunotherapy Asthma represents a spectrum from mild to potentially life-threatening disease. Rhinitis, although frequently trivialised represents a common cause of morbidity, with impairment of quality of life and work/school performance for over 12 million people, a quarter of the UK population. Whereas intranasal corticosteroids and antihistamines are eVective for rhinitis, and inhaled corticosteroids and bronchodilators for asthma, there remains a proportion of patients who fail to respond to these treatments. Furthermore these medications do not influence the underlying progression of disease such that relapse occurs within days of their discontinuation. Allergen immunotherapy (desensitisation) involves the repeated administration of allergen extracts to allergic individuals, in order to induce a state of clinical and immunological tolerance. Widely practised in US and Europe, this therapy has not been widely adopted in UK. Recent work has shown that allergen injection immunotherapy is highly eVective, safe when performed by trained persons, and, unlike inhalers and nasal sprays, may induce long term remission, reduce the onset of new sensitisations and prevent the progression from rhinitis to asthma. The sublingual route of immunotherapy (under the tongue) has allergy: evidence 65
18 December 2006 recently been shown to be eVective and suitable for home use in adults and there is encouraging preliminary data in children. There is an urgent need for research to address whether the sublingual route may also induce long term remission and have disease modifying properties. Research into the mechanism of sublingual immunotherapy, the development of biomarkers to predict the clinical response to treatment, and the development of novel “adjuvants” to improve the eYcacy of both injectable and sublingual vaccines are urgently required.
8. Diagnosis and Monitoring Disease Severity Improved diagnostic accuracy and more targeted therapy tailored for individual suVerers will help our battle to hold back the “allergic march”. In this regard identification of objective and practical biomarkers applicable as diagnostic and prognostic tools, as well as therapeutic targets will assist in clinical management of allergic disease. Biomarkers can be defined as measurements that are associated with the biology or physiology of a clinical disease process. It is critical that biomarkers are relevant, and reflect or predict patient-centred outcomes such as symptoms, quality of life, disability, exacerbations and death. A wide variety of biomarkers have been associated with allergic disease, but few are well-validated and fewer still are used in routine clinical care. For example, in asthma response to certain drug treatments are associated with genetic polymorphisms (pharmacogenetics), and anti-inflammatory treatment titrated based upon markers of inflammation measured in exhaled breath, sputum composition, and measures of airway physiology have all shown benefit compared to standard therapy. Further scrutiny of these biomarkers and the development of simpler markers are required so that these can be taken from the research arena and applied to the clinical care of suVerers with allergic disease.
9. Difficult to Treat Asthma Although asthma care has improved in the last 15 years with the advent of British and International treatment guidelines and widespread use of preventive inhaled steroid therapy, a small proportion of asthmatics continue to have severe limitation of their lives by the disease. These diYcult to treat asthmatics represent about 10 per cent of the total asthmatic population and include both adults and children, and a recent survey identified up to 7,000 adults with diYcult asthma reported by UK chest physicians. Studies have suggested these patients are those most at risk of dying from their asthma (over 1,000 deaths per year in the UK) and they account for up to half of all healthcare resource costs for asthma. They often remain symptomatic despite treatment including oral steroids (which can produce serious side eVects including osteoporosis, diabetes and hypertension). This group remains ill defined and understudied and there are no current guidelines on management of this group in the British Guidelines on Asthma. New treatments aimed at this group include anti-IgE antibodies which represent expensive treatment with poorly defined criteria for use. Recent descriptive studies have suggested that such patients are a diverse group with a high rate of misdiagnosis and co-existing psychiatric disease and poor adherence with taking prescribed medication. However at least 50 per cent of diYcult to treat asthmatics seem to have resistant asthma and recent eVorts have focussed on defining an agreed investigation and management approach to inform guidelines. A British Thoracic Society working party has been established to form a UK national network of regional centres for diYcult asthma to allow setting up of a national database for research and clinical development. Current research aims include defining sub groups who might respond to diVerent biological therapies such as anti-IgE, anti-IL-5 or anti-TNF or identifying markers of inflammation (such as induced sputum eosinophil counts) that might predict (and allow prevention) of disease exacerbations. Current research areas in this field include factorial analysis to identify disease subgroups and mapping of phenotype with genotype and patterns of inflammatory gene expression.
10. Service Delivery Interventions The majority of straightforward cases of allergic diseases including rhinitis, asthma and eczema, can be managed eVectively in primary care by appropriately trained staV, although there is clear need for specialist referral pathways for many allergic conditions including drug, food and venom allergy. We have access to an armoury of evidence-based treatments for allergic diseases, although there remain significant gaps in our understanding of some of the fundamental clinical issues in relation to diagnosis, prevention and service delivery that need addressing in order to ensure evidence-based care of allergy suVerers. In terms of diagnosis, we have no proof whether identification of a specific allergen trigger using specific IgE or skin prick testing improves the outcome of management of respiratory diseases or eczema. We have no proof which blood tests (if any) are useful in diagnosing chronic urticaria. We do not know what proportion of patients with a history 66 allergy: evidence
18 December 2006 suggestive of antibiotic allergy has measurable specific IgE to penicillin or equivalent. In terms of service delivery, there are clear, published guidelines on the management of anaphylaxis, but we do not know how often A/E treatment of anaphylaxis complies with best evidence, or whether patients with anaphylaxis get followed up eVectively and safely. We also do not yet know whether primary care-based allergy services prevent hospital admissions, or understand the extent of their contribution to cost-eVective disease management.
Memorandum by European Academy of Allergology and Clinical Immunology
Introduction Allergy is an increasingly common problem across all parts of Europe. The European Academy of Allergology and Clinical Immunology (EAACI) is a non-profit organisation whose principal aims are to promote basic and clinical research into allergy, to collect, assess and diVuse scientific information relating to allergy, to encourage and provide both training and continuous education for clinicians and scientists interested in allergy and finally, to collaborate with patients and lay organisations in the area of allergology and clinical immunology. Many of our key members are involved in research projects looking at the factors responsible for allergy in diVerent parts of Europe and separately, looking at treatments that may be eVective in reversing the trend and preventing the next generation from suVering from allergies. In answer to the specific questions:
Q1. What is allergy? Allergy is a specific immune-mediated reaction to foreign materials such as pollens, dander, food, drugs etc. Patients with an allergy will react more or less on every exposure to the substance, even when it is only encountered at low levels. Patients who are not allergic to that substance should not normally react to it. This contrasts with toxic reactions where most people will react to the foreign substance if they are exposed to enough material and intolerance reactions where people have symptoms after eating a particular food or being exposed to perfume, newsprint etc but there is no immunological recognition of the foreign substance. The distinction between allergy and intolerance has been blurred in the newspapers, magazines and general popular usage. For example, everybody understands the phrase “I’m allergic to Monday mornings” but nobody thinks you make antibodies to them!
Q2. What is and is not known about the origins and progression of allergic disease? We know that there is a genetic risk for allergy and therefore allergies tend to run in families. However, there has been a rapid rise in the number of people aVected over the last 30 years and that rise cannot be blamed on genetic factors alone. Rather, it seems that there is a susceptible group of the population who can develop allergies if they are exposed to an unfavourable environment. From clinical observations, there is a progression of allergic disease such that children may develop eczema in childhood and then go on to develop rhinitis which may or may not be followed by asthma. This is often called the “allergic march”. All three conditions involve allergic sensitisation but the targets may change with food allergy being important in infancy and inhalant allergies (pollen, dust, danders etc) becoming more important for the rhinitis and asthma. Allergies developing during childhood often regress as the child gets older. So for example, allergies to egg and milk are common in the first two years of life but rarely persist through into older childhood and adulthood. An exception is peanut allergy—children with peanut allergy aged 10 have approximately 80 per cent chance of still having it when they reach 18. People with hayfever often get their worst symptoms during the teenage years and the third decade of life and it gradually gets less troublesome as they move towards their 40s and 50s. However recent data suggests that there may occur a second allergic march starting with hay fever and progressing to persistent rhinitis, sinusitis and asthma in a proportion of these patients. Childhood asthma can disappear around puberty, particularly in boys due to their diVerential lung growth at puberty. People who have had asthma in childhood are at greater risk of developing asthma in later life, although it is not always clear whether it is recurrence of the asthma or a new condition occurring in someone who is predisposed to asthma. allergy: evidence 67
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In the longer term, some patients with asthma go on to develop fixed airways obstruction. This is part of the “remodelling” process that occurs in asthma, but it is not clear why some patients are more aVected than others. Smoking tobacco is a major risk factor but it can occur in lifelong non-smokers. No specific preventive therapy has yet been identified.
Q3. Why is the incidence of allergy and allergic disease rising?
The precise reasons are not known but it does seem to be linked to some aspects of the more prosperous living conditions that we have enjoyed since 1960. Evidence from the United States suggests that this rise in allergies was starting to appear during the 1930s and is therefore not just due to changes that have happened since World War 2. However, dramatic increases were seen between about 1964 and 1980 with continuing increases in the presentation of allergic disease to GPs and other healthcare providers at least into the 1990s. There is some evidence that healthcare usage may be levelling oV, perhaps due to changes in the way the Health Service is organised but cross sectional studies of allergic disease suggest this increase has been sustained in the UK and is continuing to be apparent in other parts of Europe. In particular, following the reunification of Germany and the increased prosperity both in East Germany and in other parts of Eastern Europe, we have seen an increase in the incidences of allergic diseases right across the former iron curtain countries. From these studies, we can tell that it is the conditions during the first few years of life that seem to matter most. For example, people born in West or East Germany before 1960 have similar rates of allergic disease, even the West Germans had much better living conditions during the 60s, 70s and 80s. However, those born in the 60s in West Germany have higher rates of allergic disease which appears to link in with the better living conditions that were present in West Germany during the 1960s. Other data from farming communities in Bavaria and Switzerland suggest that there is a critical window of exposure in the first year of life during which the child’s immune system can be influenced and their risk of allergic disease substantially reduced. Once the child passes their first birthday, the same factors that would have prevented them from becoming allergic no longer operate. This implies that any intervention to change the prevalence of allergy would have to target the very early phase of life and not be brought in at five years !.
Q4. Why does the UK have such a high prevalence of allergy?
If one allows for international diVerences in general levels of prosperity, then it is not so clear that the UK has substantially higher levels of allergy compared to other European or developed countries. Because the UK is relatively prosperous, there is certainly a higher cross-sectional rate of allergy but the highest rates worldwide appear to be in Australia and New Zealand. To the best of our knowledge, nobody has identified a UK-specific factor which would explain why we have a higher rate of allergy than would be expected simply from our general levels of prosperity. In terms of the precise aspect of prosperity that may be important, many diVerent suggestions have been made. These include changes in housing stock, changes in food technology, air pollution, vaccinations, exercise etc. It is true that modern housing and furnishing tends to increase the level of house dust mite allergens in houses. House dust mites prefer warm, damp environments which are favoured by the increased insulation of modern housing, carpeting, taking more baths etc. Reducing the level of house dust mite exposure has not been convincingly shown to reverse the trend. However, the data has often related to single interventions, such as provision of mite-proof bedding in adults and further controlled trials involving multiple interventions are needed, particularly in children who are more likely to respond to avoidance strategies. The biggest single influence on childhood immune development is food and intestinal bacteria. It is clear that there have been changes in intestinal microbial flora since the 1950s and the lack of certain gut bacteria may predispose children towards developing allergies. This is part of the “hygiene hypothesis” and is currently being tested in Scandinavia as a possible means of reducing the onset of allergy. This suggests that the change in the incidence of allergy flow from the large scale change that has taken place in food technology and our diets over the past 50 years. Other changes have been the increase in both parents working with a consequent decrease in daily shopping and rise in consumption of ready meals. Fresh foods, especially fruits and vegetables contain anti- inflammatory antioxidants which decrease on storage, those obtained from supermarkets are low in this respect. 68 allergy: evidence
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Q5. What gaps exist in establishing the overall disease burden of allergies? There are diYculties in obtaining precise diagnoses for these conditions, especially where they merge into normal health. Many people are sensitised to grass pollen, cat, house dust mite etc but have no definable symptoms or little diVerence in symptoms compared to normal healthy individuals. There is a fundamental need to understand why some “atopic” (skin test positive individuals) develop allergies (symptoms of rhinitis, asthma and eczema) whereas others do not. Many allergic conditions are handled by self-medication and do not therefore come into conventional Health Service statistics. Cross-sectional surveys are always diYcult to interpret because those with the condition are more likely to respond than those without.
Q5A. What are the social and economic consequences of allergic disease? We believe that there is substantial absence from work and school as a result of allergic disease. Importantly, allergic diseases tend to aVect young people who are either in education or economically active. Both hay fever and its treatment have clear adverse eVects on exam grades and school attainment.
Q6. What are the effects of current treatments on the natural history of allergic disease? Standard drug therapy including antihistamines, inhaled steroids and beta-agonist anti-asthma medication has no real eVect on the natural history of allergic disease. These are eVective drugs for containing the symptoms but they do not “cure” the disease in the sense of getting rid of it. They are also more useful in preventing exacerbations rather than eliminating symptoms. We do tell patients that inhaled steroids may prevent the progression of their disease but there is little hard evidence for this.
Q8. What is the evidence base for pharmacological and non-pharmacological management strategies? We have good evidence for symptom control with ordinary pharmacological strategies. For example, about 35 per cent of patients with hay fever report good symptom control with the combination of antihistamines and topical steroids, 45 per cent have partial control and about 20 per cent have poor control. Non-pharmacological management includes allergen avoidance and immunological approaches such as desensitisation. The evidence for using allergen avoidance is rather mixed. There are significant criticisms of many studies in this area, particularly in terms of failure to target advice to those patients who are likely to benefit and failure to choose correct end points. Specific immunotherapy (also known as desensitisation) is eVective on symptom control and has some eVect on the natural history of the disease. In particular, desensitisation of children with rhinitis can prevent them from developing into asthma, and may reduce the likelihood of acquiring new sensitivities. However, desensitisation is not widely practised in the UK. This reflects concerns about safety, but elsewhere in Europe and North America, desensitisation is commonly used in patients presenting with rhinitis and asthma. Sublingual desensitization is becoming available in the UK— it is amenable to home use after the first dose. A major question is whether this can, like injection immunotherapy, prevent disease progression.
Q9. Is the level of UK research into allergy and allergic disease adequate?
Allergy represents a modern epidemic in UK and Europe and there is an urgent need for more investment in research if this trend is to be reversed. Such research requires the existence of high quality allergy services at secondary and primary care level, which can serve to expand research capacity and build research networks in which the necessary clinical research and clinical trials can be conducted. EAACI would particularly welcome research across Europe looking at how diVerent risk factors operate in diVerent countries. There is quite good evidence that there are gradients of risk across Europe and these may reflect both genetic variation and environmental variations such as diet, air pollution etc. diVerent risk factors are likely to have a variable instance in diVerent parts of Europe. In this sense, the European countries represent a very useful laboratory in which to study the causes and management of allergy and asthma. Two UK Universities (London and Southampton) are already engaged in a EU-funded network of excellence (GA2LEN—Global Allergy & Asthma European Network), and others are involved in a food allergy research network (EUROPREVALL). allergy: evidence 69
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A corollary is that it is quite likely that individual risk factors may operate diVerently in the UK than other European countries, so interventions need testing in the UK, even if they appear to work elsewhere. This type of applied research needs more support and this may be forthcoming through the new DH R&D programme (research for patient benefit—RfBP). Current basic and mechanistic research in the UK is of a very high standard but funds are limited.
Q10. What are the most promising areas of research into preventing or treating allergy? Interesting data is developing in preventing allergy through the use of probiotics and nutritional strategies in childhood. These are reviewed in detail in Tricon et al 2006 (funded as part of an EU network of excellence under the sixth framework programme). Whereas drug therapies are well established, they have no impact on the long-term course or progression of allergic diseases. In contrast, the use of allergen specific immunotherapy is promising in this regard. A study of immunotherapy in children with seasonal allergic rhinitis (hay fever) has found that about 45 per cent of children will develop asthma if they are untreated, while only 20–25 per cent develop asthma if they receive immunotherapy (Niggemann et al 2006). This benefit has been sustained for 7 years after completing treatment, so it is not simply delaying the onset of asthma. Roughly speaking you need to treat four children to prevent one from becoming asthmatic. One of the four will become asthmatic anyway, and in the other two you will have improved their hay fever but they would not have gone on to get asthma. There is also an urgent need for research into controlling the long-term downstream consequences of allergic disease, particularly in relation to asthma. Further details of research priorities in allergy are contained within the submission from the British Society for Allergy & Clinical Immunology and will not be repeated here.
Q11. How effective has Government policy and advice been in addressing the rise in allergies? Current rising trends in allergic diseases argue that policies have been less than eVective, although a good example of successful intervention is the reversal of asthma mortality trends following the implementation of asthma guidelines, whereas the trend for ever increasing hospital admissions for life-threatening anaphylaxis is particularly worrying, as is the less serious but none the less bothersome allergic rhinitis that now aVects a quarter of the UK population and is associated with considerable impairment in work/school performance. From the existing data, the most important single thing we could do to reduce allergy in childhood is to reduce smoking by mothers and mothers-to-be. Maternal nutrition is probably important, but we are not yet in a position to give hard evidence-based advice to pregnant mothers. Government advice on diet during pregnancy has been of questionable value, especially in relation to peanuts. It was tempting to oVer advice that sounds sensible, but the evidence suggests this has not aVected rates of peanut allergy and may even have increased it. There is a separate issue regarding the way that the public view government information. We live in an age when oYcial information is distrusted, even when its credentials are impeccable. Advice from doctors is also mistrusted and routinely rubbished in the press and other media. Patients are left wondering who to believe and often end up going to unoYcial sources for information. Separately, there is an impression that Government is not particularly interested in allergy and has yet to be convinced that this is a significant Public Health problem.
Q12. How is current knowledge about causes and management of allergic disease shared within Government? Recently, a UK indoor environment group has been formed which is looking at the interaction between health and the environment in terms of housing and housing design. People from social services, local government, schools, architecture and the Building Research Establishment have all come together around this, although they are interested in several other issues as well as allergy. Further evidence is really required from scientific studies before one could make definitive advice on how housing policy should be altered. Food policy and labelling regulations are really two separate issues. There are questions about food policy that relate to the development of allergies and asthma. In particular, if the nutritional evidence is to be believed, then we should be looking at advice on dietary content and supplementation. Food labelling regulations are more to do with risk containment in people who are sensitised. There is a major issue at the moment regarding foods that are labelled as “may contain traces of nut”. This term has caused considerable disquiet and confusion among patients and their advisors, since there is an enormous diVerence between foods that may occasionally contain large quantities of nut as opposed to foods that do regularly 70 allergy: evidence
18 December 2006 contain small amounts. Indeed, recent anecdotal reports suggest that there is probably less nut in a food that “may contain traces of nut” than in a food that has no mention of nuts on the label. A widespread perception that food manufacturers are putting this label onto their foods in order to avoid blame for allergic reactions does not help to increase confidence amongst the general public.
Patient and Consumer Issues
Q13. What impact do allergies have on the quality of life of those experiencing allergic disease and their families? Asthma can seriously aVect patients and their families. It limits people’s life ambitions, their ability to participate in sport and in a number of occupations including the armed forces, police force, baking, car repair workshops etc. Hayfever and rhinitis have been shown to have even more impact on quality of life than allergic asthma. These are not trivial conditions, even though they do not kill very many people. Food allergies can lead to considerable psychological trauma and diYculties for children and their families. Most schools now have sensible policies in place for managing nut allergy but in the absence of any specific treatment, the whole management strategy has to depend on containing the risk exposure. This can lead to considerable friction both between parents and child and between the family and others concerned in the child’s social activities.
Q14. What can be done to better educate the public? There is a plethora of information available to the patient and public but much of it is unfiltered and can be confusing. The problem is not giving more information but making sure there is some way of encouraging people to go for high quality information. Whether this should be by oVering lists of preferred internet sites or quality stamping sources of information is a diYcult judgement. It is not helped by the fact that there are a wide range of views out there, held by both patients and practitioners. While these may be applicable to individual cases, they are not always applicable to all patients. Better access to NHS allergy services would be a big step forward.
Q15. Are current regulatory arrangements for private clinics etc satisfactory? Many alternative and complementary therapists claim to oVer allergy diagnostic tests. In some cases these are unconventional tests for diseases that are accepted by everyone to be allergic. So for example, they may oVer an alternative way of testing for sensitivity to explain your asthma or your hayfever. Others are oVering to look for allergy as an explanation for symptoms that we do not think are allergic. So for example, someone might oVer to test for an allergic basis for fatigue, headache, weight gain etc. We have to assume that the people oVering these tests genuinely believe allergies may be responsible for this, despite the fact that there is no evidence to support this belief. Obviously if anybody oVered such tests while knowing that they were false then this would be fraudulent behaviour and come under the trades descriptions act. We believe that much of the current provision of alternative and complementary services for allergy is driven by failure of provision within the state-funded healthcare sector. Even reputable tests such as specific IgE cannot be interpreted without a detailed clinical history taken by an allergy-trained individual, thus over the counter and postal testing is open to misinterpretation unless expert opinion is available. If adequate NHS advice and information were available, then it is likely that many of these private sector clinics and over the counter allergy tests would no longer be necessary.
References [not printed] allergy: evidence 71
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Examination of Witnesses Witnesses: Professor Stephen Durham, President, British Society for Allergy & Clinical Immunology, Professor Peter Barnes, Airway Disease Section, National Heart & Lung Institute, Imperial College London, Professor Andrew Wardlaw, Director of Institute for Lung Health, Glenfield Hospital, University of Leicester, and Professor Anthony Frew, President, European Academy of Allergology and Clinical Immunology, examined.
Q167 Chairman: Could I start by welcoming you Professor Barnes: I am not an allergist; I am a and thanking you for coming to give us evidence pulmonologist, but I see a lot of patients with asthma today. I am Lady Finlay. I am the Chairman of this and many patients with asthma are allergic. I have Committee. The meeting will be webcast on the done no specific training in allergic diseases. internet. There is an information note for the public Professor Durham: I describe myself as an allergist. which declares the interests of members of the Looking backwards, the dilemma is that there was Committee, so we will not be declaring them during previously no formal training for allergists until five this session. We have a lot of questions we would like years ago and therefore unavoidably my training was to ask you so if you are able to keep your answers as ad hoc, so I have been grandfathered into the term concise as possible that will allow us to get through “allergist” on the basis of 20 years’ experience. I think more and be able to come back to you with we should be looking forward, not backwards, as to supplementary questions as we go. Perhaps I can ask the best way to train allergists, which is probably not you to introduce yourselves and then we will get into through specialist training but through training the question session. allergists. Professor Frew: I am Tony Frew. I am President of the European Academy of Allergology and Clinical Q169 Chairman: As specific allergists, so allergy Immunology, and a consultant in allergy and training as outlined by the College of Physicians? respiratory medicine in Brighton. Professor Durham: It is our priority, certainly in the Professor Wardlaw: I am Andrew Wardlaw. I am an British Society of Allergy & Clinical Immunology, to allergist and respiratory physician in Leicester and equip all practitioners to become aware of, recognise until recently was President of the British Society of and treat allergy appropriately. There are diVerent Allergy & Clinical Immunology. levels that one must address. There is the specialist Professor Barnes: I am Peter Barnes. I am a allergist in a tertiary centre. We see it as our role to pulmonologist, Head of Respiratory Medicine at train chest physicians and other secondary specialists Imperial College London. in allergy, and also to increase awareness in general Professor Durham: I am Stephen Durham. I am an practice, and I think we should be looking at a multi- allergist at the Royal Brompton Hospital and layered approach in terms of equipping us. From the President of the British Society for Allergy & Clinical patient’s point of view I think that is an important Immunology. benefit.
Q170 Lord Taverne: Is there a proper career Q168 Chairman: Thank you. It has been evident structure for people who are allergists? There is a new from the way you have introduced yourselves that system now for training them but is there a proper you describe yourselves as having an interest in framework for creating posts for people as allergists, allergy. Would you describe yourselves as allergists because I have heard a suggestion that this is a lack and I wonder if you could also outline for us the route in the present set-up? by which people become allergists and quite what is Professor Durham: I think it is a chicken and egg meant by this term? situation. We need regional centres to train allergists Professor Frew: I trained as a respiratory physician and then when the specialist trainees become and a general physician and then did additional allergists we need to create posts for them to practise specialist training in allergy in London and also in in allergy. The way to look at this is to look at the Canada. I practise as an allergist and would describe needs of the allergy suVerer rather than individual myself as such. I do other things as well but I would specialist training. You are quite right to raise the certainly accept the term. issue that if we train allergists at the present time will Professor Wardlaw: My route into allergy is through there be posts for them to move into, but I think that my academic interest. My research is into the is something that needs to be addressed centrally. pathogenesis of allergic mechanisms. My clinical Professor Wardlaw: Allergy was created a speciality practice is about 50 per cent allergy and 50 per cent only five or six years ago and it has been a major respiratory medicine, and my training in allergy was eVort by the BSACI to try and establish this as a undertaken in a fairly ad hoc fashion. viable speciality. That has been through a lot of 72 allergy: evidence
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew lobbying of the Department of Health to try and do aVecting particular organs that come under the that because we need suYcient training numbers and general heading of allergy? Of course, now these are suYcient consultant posts at the end of it to make a largely handled in primary care or by other viable speciality which will provide a network of specialities. allergists around the country. At the moment that Professor Wardlaw: It is very poor, is the answer. struggle still goes on and it is far from being There are very few trained specialist centres or successful. departments dealing with allergy specifically. There are perhaps half a dozen well established allergy Q171 Lord Colwyn: Although it was a long time ago clinics in the UK and there is a certain amount of I seem to recall that the only sketchy medical training provision from clinical immunologists treating I had in allergy was how you dealt with emergencies. general allergy, which in some areas is excellent and That was it. in other areas is more variable. The problem is that Professor Frew: Certainly within the two medical for a number of reasons allergy has always been a schools I have worked in allergy has a definite place Cinderella subject and specialist allergy training, as in the curriculum. It is small but it is there and we try we have heard, is very poor at undergraduate and to make sure that everybody coming through postgraduate level. Organ-based specialists, I have to nowadays is given some basic knowledge of allergy. say, tend to be rather protective of their patch, as we At the same time, as has been said, we are trying to all are a little bit, I guess, and I think they feel that provide retrospectively some training for people at their allergy training is better than we as allergists feel postgraduate level so that everybody is aware of the it is, so we feel generally that provision of NHS mechanisms and clinical aspects of allergy as they training is very poor in the UK now. relate to their chosen branch of medicine. Q174 Lord Rea: Do you think there is a strong case Q172 Earl of Selborne: I would like to follow up the for training nurses and doctors in primary care to a concept of a viable speciality. How well co-ordinated higher level for recognising allergy and so guiding is the process whereby new treatments for allergy their more appropriate treatment? and/or their various allergic conditions are assessed Professor Wardlaw: Absolutely. The majority of and approved for use given that the term “allergy” allergy is seen in primary care and a lot can be describes a generic immunological response and the eVectively treated in primary care or in the eVects may be manifested in a range of linked community, but the problem is that the knowledge of diseases? allergy in primary care is very poor and there is no Professor Frew: The problem is that allergy is a mechanism for training primary care doctors because mechanism rather than a disease in itself and many of there is such an inadequate critical mass of people to the treatments that come forward are looked at in train the GPs. What you need first, we think, as an terms of the organ-based speciality to which they allergist is to have a critical mass and then train the relate, so treatments tend to be thought of in terms of GPs, but it is very important. treatments for eczema or treatments for asthma or Professor Frew: There is an additional issue here, treatments for rhinitis. A lot of the companies which is that there are some conditions that patients producing these compounds are relatively small have which are fairly easy to map onto the current compared to some of the large pharmaceutical NHS speciality map. For example, if you have companies dealing with, say, hypertension, and so it asthma there is going to be somebody in your patch has been diYcult to get some of the trials pushed who will deal with it at an adult or paediatric level. If forward. There are also some barriers in place, you have a food allergy it can be quite diYcult to particularly for new approaches to this. For example, identify who in the area should be dealing with it. If recombinant allergens, which look a very attractive you look at it from the point of view of the patient’s way of treating people by specifically targeting the problem, if it maps on to the organ-based specialities problem of that individual, come up against really it is easy to find somebody who at least ought to be quite strict regulations about individual components able to address it, but if they have a more general of the vaccines that you might want to use, which problem—anaphylaxis, peanut allergy—it can be make it extremely diYcult under current regulations quite diYcult to try and find your way through the to test and consider how you might get a product system to get specialist advice if you cannot get that licence for them, and I think in general the co- at the primary care level. ordination is not terribly good. Q175 Lord Rea: What short courses are available for Q173 Lord Rea: What provision is there currently in practitioners in primary care or in some other the National Health Service for specifically treating specialisms to get some improved skills for these allergy as opposed to the range of conditions things? allergy: evidence 73
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew
Professor Durham: If I may address that on behalf of Q178 Chairman: I just wonder whether such short the British Society for Allergy and Clinical courses are appropriate to provide GPs in particular Immunology, this is a very big priority for us. The with the skills that they would need to manage way we are addressing this is that we are having a patients with complex conditions and multiple primary care day or two days dovetailed into our manifestations. annual national meeting. We have organised a series Professor Durham: May I say that that is not at all of regional training days in allergy for general possible. That is why we need to increase allergy practitioners and nurses and we have a clinic list of awareness and training at all levels. NHS allergy clinics which is open and available to general practitioners and nurses so that they may attend those clinics in order to gain experience in allergy. It is really a more general approach to Q179 Baroness Perry of Southwark: My question increase awareness of allergy, to inform general follows on very much from that discussion. We were practitioners when to refer to secondary care level told by the Department of Health that they had and also, for a smaller proportion of general proposed to NICE that they should develop practitioners, to encourage them to develop a guidelines for allergy, and I understand they are specialist interest and support them through our doing that now. What guidelines would you like to NHS clinics. see? Professor Durham: Two obvious examples in terms of Q176 Lord Rea: Do you think there is a good case generic allergy treatment as opposed to organ-based for specialist nurses working in primary care to treatments would be to look at anti-IgE therapy, handle the allergy component of the workload? which is a novel therapy, and subcutaneous and Professor Durham: I would emphasise that I think that sublingual immunotherapy for those patients with is a very important component. We have the IgE mediated disease and a very focused spectrum of Education for Health in Warwick that has trained problems. Anti-IgE and immunotherapy would be some nurses from some 9,000 general practices two appropriate areas. throughout the country in the management of asthma. The same group have also encouraged training in allergy, so nurses are an important component, but we must bear in mind that this is Q180 Baroness Perry of Southwark: In general do what we are dealing with in terms of the common you think that the treatments that are available for allergic conditions. What is even more important is to allergic diseases like asthma, hay fever and encourage and make people in general practice aware anaphylaxis are clear and easy for patients to of when to refer. To give examples, food allergy, drug understand and administer correctly? allergy, venom allergy, latex allergy, occupational Professor Barnes: I would say that the current Y allergies, the patient with multiple problems, di cult therapies for rhinitis and asthma are very eVective for paediatric problems are all just the sorts of problems the majority of patients and relatively simple. The that need to be recognised and referred on. I think it mainstay therapy for asthma is inhaled steroids, plus is our role also to empower general practitioners, and in many cases a long-acting beta agonist and these are I believe the Government’s role to support not only highly eVective forms of treatment for asthma. There increased awareness of allergy in primary but also the are also eVective treatments for rhinitis. Treatments facilities at secondary care level to deal with the for eczema are less eVective, but there are patients current epidemic. where these simple treatments are not very eVective and these patients often need specialist attention. Q177 Chairman: How much supervised clinical Traditionally we would expect patients with diYcult experience is contained within the Warwick course? asthma to come to pulmonologists and patients with Professor Durham: At the present time not a lot, but diYcult eczema to be referred to dermatologists. then I think the objectives of the Warwick course are Professor Frew: One of the issues here is that for a lot to increase awareness of allergy and to empower of patients who have anaphylaxis and food allergies general practitioners and nurses to recognise allergic it is about appropriate avoidance of triggers and also conditions. It is very important for treatment to have provision of first aid therapy. There is not in that case a little knowledge disseminated widely to increase a treatment that you give on a routine basis. The awareness of the subject at the first base, but you are main issue is about access to a correct diagnosis quite right: in terms of the need to train GPs to more which then leads through to correct advice, so some eVectively manage allergic conditions it requires of it is about getting the history and then coupling more specialist services at secondary and tertiary that to the advice that is available and using the level. existing medications that are available. 74 allergy: evidence
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew
Q181 Baroness Perry of Southwark: Do you think Q184 Lord Rea: I wondered if you could see the cost there are any ways in which allergy treatments could of anti-IgE therapy coming down. Is it a question of be improved to make them safer, for example, to be patents or is it something else that makes it so used by children in school during each day? expensive? Professor Frew: As Professor Barnes has said, the Professor Frew: It really is a question of production existing treatments for asthma and rhinitis are safe costs and this links a little bit to volume of sales. and easy to use. There is not really a problem with There are certainly lots of patients that we see, who those. There is a limit on how eVective they are, so might benefit but who will not get it at the current there is room for further improvement. In relation to price this is not a question of appropriateness; this is food allergy, where what you are trying to do is avoid a question of price. In terms of the future, I do not ingestion but if they do have an accident you may think the patents are the limiting factor. I think it is have to administer injectable adrenalin, clearly what genuinely expensive to produce and it is diYcult to we would like to do is move forward to a situation see it ever coming down to the level of cost that we where we can treat this and get rid of the condition have for the standard inhaler treatments for asthma. rather than simply being there as a safety net in case somebody eats something they should not. Q185 Lord Soulsby of SwaVham Prior: Is it a monoclonal antibody? Professor Frew: It is a monoclonal antibody which Q182 Chairman: Could you explain what the place is is given in quite large quantities quite frequently, for anti-IgE therapy, whether it is only in severe and it is the combination of the frequency of disease or whether it could be used earlier on and administration, the production costs and associated should be used earlier on? hospital costs that make the treatment an expensive option. Professor Barnes: One of the problems of anti-IgE therapy is its enormous expense. It costs something like £10,000 a year to treat some patients with higher Q186 Lord Taverne: We have already had your levels of IgE, so it could only really be considered for comments that we should look more at anti-IgE very severe asthma patients, but there is no doubt therapy and immunotherapy, and that there are that some patients respond very well who have not shortcomings in the simple therapies for rhinitis and been controlled by conventional therapy, so we asthma, but in what other respects do you think the would really only consider patients not controlled on Government’s policies on the prevention and maximum doses of inhaled therapy for asthma and, treatment of allergy are adequate or inadequate and, in particular, patients who need to have steroid if inadequate, what else should we be doing? tablets that have a lot of side eVects, as potentially Professor Wardlaw: The BSACI have had a lobbying suitable for this therapy. If it were much cheaper it campaign for a number of years to try and persuade then might be applicable to a broader population of the Department of Health that what is needed is people with allergy. better allergy provision throughout the spectrum of care in primary care and through specialist care, and that what we need is a cadre of specialists who can lead the management and treatment of allergies at a Q183 Viscount Simon: Do all people with allergy national level. Of course, you are aware that there has have an altered IgE? been a big review by the Department of Health and Professor Wardlaw: That is a very profound question. generally we are rather disappointed by the outcome It depends how you define allergy. Some people of that review. They recognised, I think, that there define it quite narrowly as only people who have got was a major problem and that the NHS had not kept IgE disease involving abnormal amounts of IgE. It up with that problem in terms of service provision, can be defined more widely as conditions which have but they came up with no real solutions to that many manifestations that look like allergy or that I problem and did tend to pass the buck in my view to would regard as allergic but when that particular the PCTs for whom it is not a priority and who will mechanism is not involved. I would say 75 per cent of not pick up that buck. At the moment we feel that the allergy at least is IgE mediated. Going back to Department of Health does not have adequate Professor Barnes, it is an excellent and fascinating policies to address the allergy epidemic. treatment which has a place in a very specialist setting Professor Durham: If I may emphasise what Professor in a relatively small number of severe asthmatics, but Wardlaw has said, there was a report from the Royal could be of considerable use. It is frustrating at the College of Physicians four years ago that was moment, certainly in my experience and I suspect endorsed not only by the college but also the others’, that the purchasers are not willing to specialists within the college to encourage an purchase it very readily, which is a problem for us. improvement in allergy services in the UK. This went allergy: evidence 75
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew on to the Select Committee report which reported much closer to being able to say, “These are the two years ago. The Government saw fit at that stage things that you can and should do, and these are to set up its own review, which was something of a things that can and should be available widely across surprise to us, but then it was a year later that we had the country but currently are not available due to the recommendations and, as Professor Wardlaw inequalities in provision”. says, the problem is that they fully acknowledge that there is a problem, that there is a modern epidemic, Q188 Lord Taverne: What about advice about what that there is a lack of training and that there is a lack you should not do, again, a particular question about of resources, but provided no solutions and in my alternative medicine because I gather that 90 per cent view really ignored the recommendations of the of suVerers do go to alternative practitioners? Select Committee. The only positive things that came Professor Frew: I believe there are several reasons why out for allergy suVerers, who we should be focusing people go to alternative therapists. Some of them are on, was the need for NICE to develop guidelines, because of dissatisfaction with the availability of as we have already discussed, and the fact that we conventional services, some of them relate to popular need more trainees in allergy. This was openly views of how the body works, which diVer somewhat acknowledged in the report but the only limp from the way doctors see the world. Within reason, it suggestion was that we contact the regional deaneries is a free country, so people should be given balanced to see how this would come about with no central advice and information on alternative medicine. If funding. We have gone through this consultative they then wish to go and spend their money on these process, certainly within the North West Tees things then I do not have a problem with that. Deanery, and there is no money to encourage more trainees. That is my concern with the Department of Q189 Lord Colwyn: My flier here from Asthma UK Health review. I think it is a very inadequate response says that 5.2 million people have asthma, they lose to a major problem that has already gone through 12.7 million working days a year and the annual cost four years of consultation. to the economy is £2.3 billion. We also read that patients actually cannot even aVord the treatment, so Q187 Lord Taverne: What you say is obviously very no wonder they start going to other practitioners. Do important and disturbing but what about the advice you agree with that? that government gives to suVerers? We have heard Professor Durham: I just want to endorse the that with the current state of knowledge and the reasoning that there is such a broad practice of aetiology of IgE it is sometimes more truthful to give allergy advice available now on the street and it is an advice on what is not working. With respect to my attempt to meet the unmet need and people are forced colleague, should part of government advice perhaps on to the high street. be to avoid alternative medicine practitioners who do not diagnose and thereby often may do considerable Q190 Lord Taverne: But my question is, should they damage, or at least treat them with greater suspicion? be advised to be very careful about it because they Professor Frew: It is fair to say that the knowledge can do more harm than good? base is limited at the moment. We do not know Professor Durham: They may not do harm in precisely what to do to advise, for example, pregnant themselves. For example, Chinese remedies for or prospective mothers about how to reduce the treating eczema have been shown in five out of 12 chances of their children becoming allergic. We do cases to contain topical steroids in them, so so-called know some things we can advise them. If they ask us traditional remedies may not be as traditional as about particular courses of action, we can give them patients are led to think, but I think the real issue here the evidence that is available on whether, for is diverting patients from the care that they need. If example, avoiding peanuts in pregnancy might be they have acute severe asthma they need to be helpful or not, but we are still short of accurate managed by a pulmonologist and have access to information and, of course, it is a diYcult thing to do emergency facilities. If they have multi-system because you are making decisions at a very early disease they need to see a specialist allergist at a one- stage in life with children who are healthy in order to stop-shop that can deal with the allergic components try to prevent something happening some years of all those diVerent conditions at one visit and that downstream. These are long, complex studies which is not the sort of thing that you get on the high street. are usually beyond individual institutions or individual funding bodies to put money towards, and Q191 Lord Colwyn: There are only 14 in the UK. I think there is still a need, and it will be covered in Professor Barnes: I do agree with your concern that the next session, for further research in this area to alternative therapies are widely used to treat allergic improve the advice that we can oVer people to diseases and, of course, are promoted by the media, prevent it. In terms of advice on treatment, we are whereas often conventional therapies are criticised by 76 allergy: evidence
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew the media. The fact is that almost all alternative There are two points I would like to make about this therapies, at least for asthma, that have been tested treatment. First of all, in those defined circumstances by adequate controlled trials have been shown to be it is extremely eVective and it does things that completely ineVective. I think it is our duty to try and conventional medications do not do: it induces long warn people that these treatments are not working term remission after stopping the treatment. In because people pay money for those therapies and, as children you can actually prevent the onset of new Professor Durham has said, the danger is that they sensitisations by treating children earlier, and there is may stop using conventional therapies that are some evidence from randomised control trials that eVective. I think some practitioners advise people not you may prevent progression, for example, from to take conventional medicines which have quite a rhinitis to asthma, so there are very good reasons for bad press, so I think it is an important duty to warn prescribing this therapy in patients who fail to people about the ineYcacy of alternative therapies. respond to the usual therapies. The drawback is that Professor Wardlaw: On the specific questions about with conventional immunotherapy that is given by government advice, I would say that the Government injection there is a risk of inducing systemic allergic should not be funding alternative remedies that are reaction, and in the United Kingdom it is specifically not based on good scientific evidence. That is where contra-indicated in patients with chronic asthma. In the Government’s work should be. Obviously, we are previous times when there have been adverse eVects all very regulated now in our practice and they should they have been in patients with chronic asthma. It also be making sure that patients are not exposed to does have a role. It has a limited role in patients who treatments which can be harmful, and that does fail to respond to usual therapy. In terms of research include, I suppose, situations where the patients and development, if I may just extend that answer, we would otherwise be prevented from taking beneficial know this form of therapy is eVective but if we could treatments. make it safer or develop novel strategies for Lord Colwyn: If they are available. immunotherapy then it may be more broadly available. In this context recently there has been Q192 Chairman: Could I go back very briefly to the developed a sublingual form of immunotherapy, not workforce planning because we have heard that the by injection but taken under the tongue, which is used Walport clinical academic trainee numbers have been for patients with severe hay fever. This treatment has V increased by, I think, 11 going into allergy training. been shown to be e ective and has also been shown Do you think that is going to be adequate to address to be safe such that the patient is able to take this the need? form of therapy in their home. Professor Frew: I think it will help in terms of building the academic workforce. It is not going to help in terms of building the service workforce. Professor Wardlaw: I think it has got no role for allergy. The Walport scheme is not, except maybe in Q194 Lord Soulsby of SwaVham Prior: Why one or two centres, suitable for allergy. sublingual? Is there lots of tissue that can process it? Professor Durham: I think the answer to that question Q193 Lord Soulsby of SwaVham Prior: We are is yes. If we look at animal models using the oral dealing with immunotherapy and you have route, it is a very eVective way of inducing mentioned IgE but, apart from IgE, what other immunological tolerance, and this is a natural immunotherapies are used? extension of that work on animals. The evidence base Professor Durham: There is the treatment referred to has accumulated over the past 10 years that this is an as allergen immunotherapy. This treatment is used eVective way of inducing tolerance to selected quite widely in Europe but less so in the United allergens, in particular to grass pollen and also to tree Kingdom. It is only indicated in patients with IgE pollen. Those are the two areas where this has been mediated disease and it is eVective in patients with a shown to be particularly eVective. If you look at the limited spectrum of allergies. It should be prescribed 12 million hay fever suVerers in this country, 23 per and administered by trained people in a specialist cent of the population, 40 per cent of those would say environment. The people who are most likely to that they currently are dissatisfied with their therapy, benefit from immunotherapy are two groups of and this is work from Professor Frew’s group, so I am patients. There are patients with severe hayfever quoting work from his group. Probably 75 per cent of which does not respond to conventional treatment, that group are not taking the treatment appropriately and the second group, in whom the treatment is life- or regularly, but there is a hard core of suVerers, I saving, is in patients with venom anaphylaxis from would suggest between half a million and a million, stinging insects, wasps and bees. The point about this who would really benefit from the sublingual form of treatment is that it is not like prevention treatment. this treatment which has been shown to be eVective. allergy: evidence 77
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew
Q195 Lord Soulsby of SwaVham Prior: We are not going to allow them to go through on a understand that immunotherapy is more commonly mutual recognition process, which is the normal way used on the continent of Europe than in this country. by which these vaccines would have been made Is there a reason for that? Should there be more available in this country. We are not entirely clear courses? why they are quite so concerned about this but there Professor Durham: Could I defer to Professor Frew has been diYculty in getting allergist opinion, if you on that? will, to speak to the CSM and the MHRA because Professor Frew: I deal with allergy in diVerent parts of there are not many allergists around, there is no Europe and am very familiar with the diVerences in allergist on the committee, and therefore sometimes practice there. Most of these are just historical. the opinions that are expressed there are rather anti- It is the way the services have developed in immunotherapy. diVerent countries. We used to do quite a lot of immunotherapy in this country but it was done at the Q196 Lord Soulsby of SwaVham Prior: In view primary care level. People from the allergen of the success of the sublingual approach to manufacturer used to go around, make the diagnosis immunotherapy what is the potential for treating and provide vaccines for use in general practice food allergies by sublingual application with selected surgeries. There were a number of problems with this, items of food? and indeed between 1952 and 1986 there were about Professor Durham: If I may, my Lord Chairman, I will 27 fatalities associated with immunotherapy, almost ask Professor Frew to address the food allergy issue. entirely patients with severe asthma, as Professor In relation to hay fever, I think we should be Durham said. The CSM, the Committee on the cautious. We have phase three trials now that show Safety of Medicines, then put some restrictions on that sublinguals are eVective and we have good safety immunotherapy and said that it could only be done in data from 2,000 patients. In terms of its fragmented places where they were familiar with its use and had distribution I think we would want to see good safety resuscitation facilities available. Ironically, if that data from 20,000 patients. I think there has to be a happened today, general practices have those cautious introduction through specialist centres. I facilities available to do it but in 1986 they did would be concerned if this form of therapy was not and so eVectively it stopped the practice prescribed ad hoc at this stage by general of immunotherapy at a devolved level in the practitioners, for example. I think to inject community. We were then thrown back on to the enthusiasm but also an element of caution to the very small number of centres that were doing sublingual route is important. immunotherapy and it meant that for logistic reasons patients have not been able to access this. For Q197 Lord Colwyn: The sublingual route is not new. example, in Southampton and in Bournemouth, It has been used for thousands of years. It is used where I was working until last year, we had very when someone is having a heart attack. The first active clinics doing desensitisation but we also saw thing you do is put aspirin in sublingually. many patients who would come from some distance Professor Frew: Absolutely, and many drugs are away to see us, but who were simply not able to make absorbed very eYciently from the mucosa in the the repeated journeys to come and get the treatments mouth. It has the advantage that it gets into the done and would have to decide that they could not go system quickly and bypasses the liver. If you give a through with this. The other issue is again about the drug via the gut, it takes time to get there and is organisation of the NHS, that because we are metabolised as it goes through the liver, so putting organised around organ-based specialities, many of something under the tongue is a very eYcient way of these patients, when they were sent up from the getting some drugs into the system. In the case of general practice, went to see somebody who was not sublingual immunotherapy, what you are hoping to very allergy oriented and who thought that it was not do is to present the allergen to the immune system by appropriate for them to have immunotherapy. The getting it taken up by specialised cells in the lining of third point is that when we have gone back to the the mouth. In terms of food allergy, there is a lot of MHRA, as it is now, to try to get product licences for interest in developing vaccines, for example, to some of the vaccines, the MHRA have taken a very peanut allergy. There is some very good work being stern line with this. It has been much more strict in done on peanut allergy in the States, mostly in terms terms of the regulation than other parts of Europe, so of injection vaccines, but, if we could get a sublingual they have derogated from the mutual recognition vaccine for it that would be easier for patients to process which would normally allow for these administer. The problem I see at the moment is that vaccines to be available in this country and told the with peanuts you are dealing with anaphylaxis and so companies concerned that they may be available in the risk of precipitating the condition you are treating Sweden and Denmark and other countries but they is higher than it is with hay fever, where it does not 78 allergy: evidence
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew matter if you make somebody’s nose run but it does Q202 Lord Rea: What I wanted to ask has been matter if you give them anaphylaxis. Many of the addressed by that question. My question was about patients with peanut allergy react to extremely low the durability of the immunotherapy. Is it ever levels of peanut. Just touching peanut to the lip can completely lifelong or has it always failed? I declare precipitate an anaphylactic reaction. The stakes are an interest here because I was a patient of Professor higher in that situation in terms of the risk of causing Durham in his clinic and was successfully side eVects, but also the benefit to patients and desensitised from wasp venom. particularly children would be enormous. Professor Frew: There are diYculties in the natural history. If we take the wasp venom issue, if you look Q198 Lord Taverne: Is the sublingual method of at how likely people are to have anaphylaxis, the risk treating it diVerent from the pill that was recently gets less with time, so once you have gone 10 years referred to? after a sting your chances of having anaphylactic Professor Durham: No. That is the sublingual route. It reaction are really quite low; they are about five per can be given either in the form of drops or as fast- cent compared to nearly 75 per cent the month after dissolving tablets. you have had that anaphylactic reaction, so there is a natural improvement that goes on and you can bring the risk right down at the beginning by treating with Q199 Lord Taverne: The second question is that you immunotherapy. It is very diYcult then to do 10 mentioned that there were risks associated with years’ studies to follow up placebo controlled studies injection, but in the paper which you submitted to us to see what is going on at the end of it. In terms of hay it did say that injection is highly eVective and safe fever, we have many patients who come and tell us when performed by trained persons. that they had immunotherapy in the seventies and it Professor Durham: Yes. cured their hay fever and they are now 20 or 30 years down the track and they do not have symptoms. We Q200 Lord Taverne: Is the risk because people are simply do not know what would have happened to not properly trained in administering it or is there them if they had not been treated because there are no something inherently unsafe about it? controlled trials that go that sort of length. Professor Durham: No, it is two-fold. First of all Lord Rea: I am prepared to submit myself for further people do need to be trained in the administration of testing if required. the treatment and, secondly, the patient has to be in an environment where, in the unlikely event of a Q203 Baroness Platt of Writtle: How do allergists severe reaction occurring, that can be recognised and communicate with appropriate organ specialists such promptly treated. This is why it really is confined to as chest physicians and dermatologists in improving specialist centres. Having said that, I think it is safe the management of patients with allergic diseases, when prescribed in those circumstances and is highly V and should chronic severe asthma be managed by e ective and may induce long term remission in the allergists or chest physicians? selected group of patients that I have described for Professor Durham: Certainly speaking on behalf of you in terms of venom, anaphylaxis and severe our national society, it is a major priority for us to unresponsive hay fever. empower secondary care specialists in individual specialities—dermatologists, respiratory physicians, Q201 Lord Taverne: But in the case of other immunologists—in how to manage allergy desensitisation is it something that is only temporary eVectively. I think it is in the interests of allergy in its eVects or is it something which often leads to suVerers that the wider the knowledge of allergy long term remission? management within the speciality the better, and if Professor Durham: The evidence for long term we just keep our eye on the ball in terms of keeping remission is in the context of the subcutaneous route our eye on the patient, I think it is important that we at the present time, and there are now some six or continue that mission which is central to our society. seven studies that have shown that if you give In terms of chronic asthma, I think chronic asthma injection treatment for hay fever or pollen allergies should be managed by chest physicians with input due to grass or trees for a period of three to four years from allergists where appropriate. As Professor you can induce a long term remission for at least three Barnes has highlighted, there is a large proportion of to four years after discontinuation. That is also true patients with chronic asthma who are adequately in the context of venom anaphylaxis to wasps and managed by currently available therapists. I think the bees. For the sublingual route the evidence is in the contribution that the allergist has to make is that they phase of evolution at the present time. There are two identify and treat underlying causes where possible. control trials at the moment that will deliver that In terms of chronic asthma I think the overall information within the next five years. approach of an allergist to consult a patient with allergy: evidence 79
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew chronic asthma can be very valuable. For example, I which I think is very satisfactory, is that people with have strong links with Professor Barnes at the severe asthma get managed by chest physicians Brompton, and he sends me occasional patients to because it is important to have people who assess from the point of view of their allergies, for understand other lung diseases that can present with example, food allergies, which is one very good symptoms like asthma. Some patients will need example. The presence of asthma is a major risk critical care and, therefore, specialists would have an factor for sudden death in patients with food allergy. input into that. The allergist has a very important I think it is the allergist that should be treating here, role as a specialist adviser because there are situations and although it is uncommon in adults with asthma with severe asthma where you need the advice of it is a life-threatening combination which needs to be allergists, so it is very important for allergists to be in recognised and appropriately treated. We have not tertiary centres but not looking after severe asthma talked much about paediatric practice but the routinely, which I think is better done by pulmonary combination of food allergy and asthma in children specialists. I would say the same would apply to is a potentially lethal combination which in my view people with severe eczema which has to be should be managed by a paediatric allergist. distinguished from other skin diseases. In some patients it may be very helpful to have specialist Q204 Baroness Platt of Writtle: In the oral evidence allergy input. we have heard that GPs are not suYciently trained, and you have emphasised that today, in allergic Q206 Lord Taverne: Is it correct that something like diseases. What do you think needs to be done to 30 per cent of asthma suVerers have not been oVered ensure that GPs can deal with allergic disorders in an allergy testing? appropriate way and then refer patients to be more Professor Frew: We have no idea because we do not suitably treated by specialists? see them. The majority of people with asthma will not Professor Frew: I think medicine is changing at the get to a specialist clinic and they certainly will not get moment and we no longer exist as people who have a to a diYcult asthma clinic, so it is diYcult to get to the large body of information in our heads that we keep denominator. That information would have to come private and people come to see us. Part of our job is from the community, from rather more dispersed to put our information in the public domain, so we go things than our patient base. out to meet people and in our various societies in Professor Barnes: I would say that skin testing for Europe and in Britain we go out to the GPs and allergies is not very helpful in the management of specialist societies. We are thin on the ground so we asthma because we treat patients with the same cannot go to every single meeting that happens and management whether they have allergic or non- we know that the primary care level is very local. You allergic asthma, so it is not so critical for the have to go around small areas to do this; you cannot management of asthma in general practice. expect all the GPs to come together in one place, and Professor Wardlaw: I was going to say that I agree so part of our job is to provide information via the with Peter, but I think that is where Peter and I would internet with appropriate guidance on how to profoundly disagree. Severe and diYcult asthma in manage people prior to referral. There are NHS particular should be managed primarily by chest systems that do this as well, and again we try to have physicians but the allergist has a huge role to play input from the specialists to make sure that the advice because it is amazing—with colleagues I probably they give to general practitioners when they are not run one of the biggest severe or diYcult asthma sure what to do is appropriate and helps them to clinics in the UK—how these very excellent manage allergies in the community. We are not in the physicians sometimes forget about the allergy business of just going out and touting for business. perspective, which I think is hugely important. You We want people to be managed in the community cannot make any judgment about an allergic where possible and we want people who go to their perspective unless you do some tests and one of the GP asking for a referral to be able to get a hearing for major problems for primary care is that they cannot that and, if it is appropriate, to get referred to diagnose allergy because they do not have access to somebody who can help them with the problem and this relatively simple but hugely important test. In has the time and expertise to do that. diYcult and severe asthma, and other forms of asthma actually but it is more important in asthma, a Q205 Chairman: Professor Barnes, I think you large proportion of patients do have an allergy wanted to come back on the previous question. mainly to their pets, their cats, dogs and rabbits, Professor Barnes: Yes. I would just like to address the which plays a very big part in their disease but the issue of specialist management because I think this is problem is they will not get rid of their pets, and that really a critical issue in this discussion about the need is a separate thing. Peter and I would profoundly for allergists. At the moment the way things work, disagree on the role of allergy in that context. 80 allergy: evidence
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew
Q207 Viscount Simon: Professor Frew, in your problems. If you can do that at an early stage at a submission to us you mentioned intolerance one-stop shop and nip the problem in the bud you reactions which from my reading means all kinds of will avoid the patient going oV on a crusade into the things that can cause certain reactions and it would high street or seeking alternative opportunities to be diYcult to establish what they are. In these treat what they conceive as allergies. An important circumstances would the patient be referred to a chest role of the allergist is to exclude allergy as a cause of physician or an allergist immediately? non-specific symptoms, including food intolerance Professor Frew: Again, I should make the point that and all the other things that come up under the guise these things are not mutually exclusive. I am trained of allergy. It is exclusion of allergy. The problem is as a chest physician, I see lung cancer, critical care, that the general practitioner is not equipped to do and acute medical emergencies as well as dealing with that. If the patient comes in and says, “I have got an allergies, so there are people in the community who allergy”, it is very diYcult for the GP to say, “No, you bridge that gap and it is not necessarily two diVerent do not” if he is not familiar with the diagnosis and people who would be seeing it, although you might be treatment of allergy. I believe the same is true at the wearing a slightly diVerent hat. If we are talking secondary care level within specialties. Many of my about intolerance reactions, the first issue really is to referrals are, “Is allergy related to this problem?” and take a proper history. Sometimes people get into the I can write back and say, “No, it is not” and trap of saying “I am intolerant of milk” or whatever, everybody breathes a sigh of relief and the patient is without defining in what way they are intolerant, so happy. You need somebody who recognises the beast quite a lot of our time is spent sitting down trying to in order to exclude it and that is an important role of get the patient to tell us what is wrong with them, not allergists. in terms of what is causing it but in terms of what symptoms and problems they have. It is quite interesting that a lot of people have constructed great Q208 Lord Colwyn: When my two younger scaVolding around symptoms such that if they go to daughters, who are in their mid-twenties now, were in eat a pizza in such and such a place they will get a their twos and threes they used to have the usual problem but not in other places without someone problem at this time of year with respiratory sitting down and saying “What is the problem and breathing problems and, of course, the GP suggested how consistent is this?” It is general medical skills but corticosteroids. At the time I resisted that and found it is specialist practice in the sense of having enough it easier to stay up night and day. I must not say that, time to sit down, to force the patient to tell you what my wife used to stay up night and day. We resisted the they actually have in the way of symptoms and then corticosteroids and just watched them because I felt try to map back and say, “When do you get these? they only tackled the symptoms of the disease rather What are the circumstances? What do you think is than treating the cause and the progression. Would causing them? What is the evidence for that?” That is you agree with that? Would corticosteroids make a the approach allergists are trained to do because disease worse because they are aVecting the immune quite a lot of patients believe, rightly or wrongly, that system and depressing that? allergy, particularly food allergy and intolerance, is Professor Barnes: Corticosteroids are highly eVective responsible for a variety of non-specific symptoms. treatments for allergic diseases but people have been The term “food intolerance” was brought in because concerned about the side-eVects of steroids and the the term “allergy” was being slightly abused. We reason we use inhaled steroids for asthma is to avoid would use “food allergy” to mean when there is an the side-eVects seen with steroid tablets. For most immune reaction against the food which is causing patients these treatments are extremely safe because the symptoms. If you eat something and it disagrees only low doses are needed. However, they do not deal with you but there is no immune reaction, what are with the underlying cause of the disease because you going to call that? “Food intolerance” is a useful although they can completely control the disease, portmanteau term that says, “When you eat this food when the steroids are stopped usually the symptoms in a certain quantity you get predictable symptoms come back. They are the most eVective treatment we and the food disagrees with you” and it is without have now but clearly there is a need to find treatments prejudice to the mechanism, it allows us to have a in the future that will switch oV the disease long-term. term that we can use to talk to the patients without Professor Durham has already talked about implying that it is caused by an immune reaction to it. immunotherapy in that context but there may be Professor Durham: If I may make a point that I think other drugs that can be developed that are curative, is extremely important. If you open any journal or or at least have long-term eVects. I think inhaled magazine it will tell you that allergy is the cause of the steroids have had rather a bad press in the general problem and a huge role of the specialist allergist is public and in the media because of the side-eVects that he is equipped to exclude allergy as the cause of that people know about steroids in general. allergy: evidence 81
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew
Q209 Lord Colwyn: Are you saying that, in fact, symptoms, and to work that out you need a little bit there are no side-eVects from long-term use of more insight and knowledge. My general advice to inhaled steroids? patients who come armed with this information, and Professor Barnes: No important side-eVects at the usually they have been and had the tests before they doses most patients need to control the disease. Only see us, is “Can we just talk about your symptoms first patients who need high doses may have some side- before we talk about whether or not the test result is eVects but usually these are not serious. They do not important”. deal with the underlying disease problem, so for the future we need to find more curative treatments. Q213 Lord Rea: What do you think of the idea that Professor Durham: And also identify and avoid all general practitioners should have a kit rather like provoking causes which requires a careful history those because they would be able to interpret them and knowledge of the problem without any with a bit more knowledge? V medication in that context. Steroids are very e ective Professor Frew: We are going back to this issue of who by the inhaled route and they are the right treatment it is in the practice who will be dealing with allergy. in that circumstance but it is also important to The majority of regular straightforward asthma is identify provoking causes and avoid them. I think now managed by practice nurses, not by general that is a particular role the allergist can contribute. practitioners. There is an interest in whether practice nurses could also take on the role of doing allergy Q210 Lord Colwyn: Do some patients not respond diagnosis and advice. There is quite good evidence to corticosteroids and how do you deal with that? that they can do the tests perfectly well, there is not a Professor Barnes: There is a condition called “steroid- technical problem with doing the test, but sometimes resistant asthma” but it is extremely rare, we think it there is some over-interpretation of the results. With happens in about one in 10,000 asthmatics. There are any test that is done you need to know its strengths other people with more severe asthma who are and weaknesses and my view is if there is a diVerence relatively resistant, which means they need high doses between what doctors and nurses do it is that doctors of steroids, and again they are relatively uncommon. are more concerned with the diagnostic aspects and We are talking about one per cent of asthma patients. we use our specialist nurses predominantly for managing the condition rather than for making the Q211 Lord Colwyn: Would they be treated diagnosis. I do not see skin testing by nurses as a systemically? panacea. I do think, however, it would be useful to Professor Barnes: They may require systemic steroids have it available and we are trialling this at the or some other treatment like anti-IgE that we talked moment, in the community to see whether you about earlier. can improve people’s care by doing skin tests and providing standard protocol advice for Q212 Baroness Perry of Southwark: You mentioned straightforward allergies. The one thing we already the diYculty that GPs do not have any facility for have is evidence that patients are very pleased about good diagnosis, what do you think about these over- this because it is delivered close to them at home and the-counter allergy tests that are currently being they find the information useful. oVered? Are they of any value for patients at all? Professor Frew: I would say largely no. The reason for Q214 Lord Soulsby of SwaVham Prior: Coming back that is any test you do in this area needs to be to over-the-counter tests, how many of these have interpreted in the light of a history. I am not trying to been looked at from the point of view of eYcacy and make work for doctors but if you have not got the safety in the way that you would look at non- history and do a test it will be misleading. Very often complementary or alternative medicines? the patients have gone to get the test because they Professor Frew: If you do an internet search—we did have self-diagnosed the problem. There is some this earlier this year—looking for home allergy tests usefulness in tests. Those tests are mainly useful when in the US and Europe there is a huge range, anything they are negative. For example, if you were from a small questionnaire which is about trying to contemplating spending your money on allergen identify allergic triggers through to about £1,000 avoidance covers for your bed and you went and got worth of blood tests. There is very little back-up a test which showed that you were not allergic to advice on this, so people are encouraged to pick their house dust mite you would have saved yourself and own level of tests, gold, platinum or silver, and the the health service quite a lot of money. If you came test is done without much input from the patient. up positive there would be no guarantee that the Some of these tests are standard laboratory tests that bedding covers you were about to buy would be will be done in every NHS hospital; others are tests eVective because for about half the people who have that we do not think have any value at all. It is very a positive test it is not important in driving their much like the internet, it is a wide open market. They 82 allergy: evidence
18 December 2006 Professor Stephen Durham, Professor Peter Barnes, Professor Andrew Wardlaw and Professor Anthony Frew really ought to get some advice but tests are available work; the evidence is it probably does not do much and out there and if people want to pay for them then good. There is also quite a lot of unconventional they can. diagnosis for conventional disease, so you have got people using very odd techniques to diagnose causes Q215 Lord Soulsby of SwaVham Prior: There is no of asthma, causes of eczema etc. The third issue is system of kite mark or anything like that with some unconventional tests for diseases that we do not think of these tests? have anything to do with allergies at all, things like Professor Frew: Not that I am aware of. migraine or hyperactivity disorder in children. If you go along, people will do tests for you and tell you that Q216 Lord Soulsby of SwaVham Prior: I can see the such and such a thing is causing your disease. I think V problem is that some patients feel that they are you have to separate those things o because the first relying on these things absolutely, but if they are not one is legitimate as an option that people may choose eYcient— to follow but the other two are straying into areas Professor Frew: I think there are two separate issues where we think the science is not there at all. there. One is the quality of the test. If the test Professor Durham: What one has to do is evaluate the measures what it says it measures then generally evidence. As Professor Barnes has pointed out, when speaking that would be dealt with by quality control any homeopathic treatment, for example for bronchial asthma, has been put under scrutiny it has in the lab. There is a separate issue about whether the V test tells you anything about your condition, which in not been shown to be e ective. My personal view turn depends on what your condition is and on the is those resources would be better invested in possible connection between the problem you have conventional NHS allergy centres rather than got and whether the test is informative. That is not homeopathy. On the other hand, of course one has to kite markable because it depends on what your acknowledge the fact that patients and the general population are very supportive of the concept of condition is. It is up to the buyer to either get advice homeopathy. For me that is not a reason to continue from their practitioner or to know enough about it to this and I would support what Professor Barnes has know that this test is appropriate for that. said. Chairman: I do just wonder whether the diagnostic Q217 Viscount Simon: At the moment there are five step and the time taken to take a good history may be V NHS hospitals which currently o er homeopathic helpful and that may need to be separated out from and other alternative medicine, two of which have the administration of diVerent medicines. special allergy clinics. Should the NHS provide alternative therapies for allergies alongside these Q219 Lord Colwyn: Can I just remind you that more conventional treatments? the perfect solution is the use of high dilution Professor Barnes: I think the answer is no. sublingually, which we have heard before this morning. Q218 Viscount Simon: The fact you say “no” does Professor Durham: As opposed to very high doses not surprise me. sublingually which are eVective. Professor Frew: There are three diVerent parts to this. Chairman: Thank you. If there are additional points The first is homeopathic and other unconventional that you would like the Committee to consider please treatment for conventionally diagnosable disease, do feel free to write in. Could I particularly thank you e.g. homeopathic treatment for hay fever, if you want all for the written evidence you have already to you can go out and get that and it may or may not submitted to us. Thank you.
Examination of Witnesses Witnesses: Professor Tak Lee, Director, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, Dr Diana Dunstan, Director of Research Management, Medical Research Council, Mr Dave Allen, Senior Vice President in GlaxoSmithKline, Head of Respiratory Drug Discovery and Professor John Westwick, Global Head of Respiratory Diseases, Novartis Institute for Biomedical Research, examined.
Q220 Chairman: Thank you very much for clear, we are being web cast and the information coming today. I know some of you have listened note of declaration of interests is available to the in to the previous session so there may be public so, as I said before, we will not be reiterating additional points you would like to make. We do those. I wonder if I could start oV by asking have a lot of questions we want to ask so if you you to say who you are and then we will go to could try to keep the answers short. To be quite questions. allergy: evidence 83
18 December 2006 Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen and Professor John Westwick
Professor Lee: I am Tak Lee. I work at King’s College, on multi-disciplinary partnerships and on large London and I am the Director of the MRC-Asthma cohort studies and multi-centre bodies, which will be UK Centre in Allergic Mechanisms of Asthma. very expensive. I think it is very likely that if we are Dr Dunstan: Diana Dunstan, I am Director of going to pursue a strategy to impact on the epidemic Research Management at the Medical Research of allergy in this country it will have to be funded Council. through some sort of partnership arrangement. Mr Allen: Good afternoon, I am Dave Allen. I am a Senior Vice President in GSK, Head of Respiratory Drug Discovery. Q223 Earl of Selborne: Dr Dunstan has told us Professor Westwick: My name is John Westwick, I am something about the work of the Medical Research the Global Head of Respiratory Diseases for Council and its funding on research into allergies. I Novartis Institutes for Biomedical Research. wonder if we could hear more about how the research councils determine what projects are suitable for funding. She also referred to the 14 year longitudinal Q221 Chairman: Thank you. Could I remind you study in Bristol and this is a long timescale for a that this room has a very high ceiling and an echo, so research cohort and I suspect that other such research if you can speak up. Do not worry about shouting at into allergies will require studies over a longer period us; clarity is all. I wonder if I could start by just asking you how the various charities and professional bodies than is normally convenient for funding lines. Could in the UK, such as the British Society for Allergy and we hear something about whether there are any Y Clinical Immunology, Asthma UK and Research di culties, therefore, in funding some of these long- Councils UK, work together to promote research term studies? into allergic disease. Dr Dunstan: Talking about the general mechanisms Dr Dunstan: The MRC and, indeed, the other for funding research, people come to us in response research councils, work closely with charities when it mode and if their proposals are good enough, and is appropriate. I think perhaps the best illustration I they have to be pretty good actually to get funded have got of that is in the respiratory medicine area we by MRC, then they are funded. We do have have been working very closely over the past two or other mechanisms. Recently we have had calls for three years with Asthma UK, the British Thoracic proposals for experimental medicine and there have Society and other charities to develop respiratory been some respiratory medicine asthma proposals medicine in the UK and, of course, a large part of that funded in that call. We had a call for biomarkers and is asthma work. We have funded, together with there were none. I looked before I came today and Asthma UK, the centre that Tak Lee directs. We also there were no proposals in that that were relevant to support with the Wellcome Trust a number of studies allergy. We fund training, so individuals apply to us jointly and one of those that might be of interest in for training grants. We fund PhD studentships, view of your previous discussion is a longitudinal fellowships, senior fellows, that kind of thing, so study of patients and children in the Bristol area, there is a wide range of things there. As you say, we 14,000 children, so we are following them right do fund long-term work. Long-term work is partly through and they are now 14. done in our units and institutes. That is largely basic Professor Lee: In the last few years there have been work. We do quite a bit of work in relation to allergy three national consultations on strategy for asthma in three of our units. Mainly the cohort studies are research sponsored by Asthma UK. The most recent funded in partnership with other funders because, one has just been published. Those consultations, as you point out, they are expensive. We have which are national, involve a number of bodies. They mentioned the Avon ALSPAC long-term study and involve the MRC, the British Thoracic Society, the there is also a Southampton Women’s Survey that is Wellcome Trust, NICE, the Department of Health relevant to diet and food intolerance. That is a long- and industry in various capacities. There are liaisons term study following women prior to them being and collaborations mostly in asthma. If you are pregnant, through pregnancy, and the children after talking about allergy in the wider context there is not birth. Most of the children in that study are now three much of that going on. or four years old. In the long-term study area we are looking at all the cohorts that are funded now in Q222 Chairman: Are there areas where you conjunction with other research councils and other feel communication could be improved between funders so that we can best fund the new sweeps diVerent bodies? needed, so we have decided to have a partnership on Professor Lee: I do. I think we have a lot to gain by funding these long-term cohorts. You are quite right, working in collaboration and in conjunction. As I am they are very expensive and it is important that we sure we will touch on, my view is that the way have a partnership looking at the sweeps so that forward in allergy research in the future will depend everything that needs to be included in a particular 84 allergy: evidence
18 December 2006 Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen and Professor John Westwick sweep is included and nothing is missed out and we clinical centres. I think one of the most exciting things can all contribute to the funding. was what was touched upon by your previous body as to whether we can produce disease suppression or Q224 Earl of Selborne: Would you expect the immune deviation. There is a lot of that sort of proportion of the MRC budget on these long-term work going on now either funded by various studies to increase? academic institutions or charities or pharmaceutical Dr Dunstan: I would certainly expect them to increase companies. You heard about the various sublingual over the next few years because we know two or three approaches and there are other things going on where of them are coming up to their next sweep. there is some evidence that you can cause some long- term immune deviation moving away from an Q225 Lord Taverne: You obviously have to look at allergic response to a non-allergic response which how strong the particular case is for a particular lasts for at least between one to two years from the study, but do you also have an overall view about studies that have only been done for about six which are the most important studies to do, which are months to date. the most urgent ones? Is there a way of considering the priorities of these? As far as the expense is Q227 Lord Colwyn: So when there is some massive concerned, obviously the fact that they are long-term breakthrough, being a commercial institution do you studies makes them expensive but how far are they not keep quiet about it? somewhat disadvantaged by the fact that you also Professor Westwick: No, there is always pressure to need very large numbers of cohorts for infants or publish. With things like that, the people you link up whatever it is? with need to publish as well so something as Dr Dunstan: Priority-wise, the boards that look after significant as that would be published. these particular subject areas have priorities in their Mr Allen: Basic research is pre-competitive, it really minds. Every year they look at their portfolio and is in everybody’s interests to share it because you they point out areas of priority. The boards that look want the scientific community to debate and input. It at the proposals that come to us and assess them for is very rare that a piece of really fundamental science funding have priorities for their areas and they will would break that would be a secret for more than apply those priorities when they decide on which ones about 20 minutes. are going to be funded. In the asthma area, respiratory medicine, that is a high priority for one of Q228 Baroness Perry of Southwark: I think my first our boards. We have got about 15 proposals that we question is to Mr Allen. When pharmaceutical funded last year in response to a call and clearly they companies are deciding where to put their research were applying the priorities in that case. Expense is eVort, do you tend to put it into allergies in totality or always a problem but if the research is good enough do you go down the route of individual disorders? and we have enough partners to contribute to the Mr Allen: The short answer is that we do both. It is expense then I think we can cope, and that very important to us to focus on application of need particularly applies to the cohort area. when we are looking for new medicines. To do that Mr Allen: I wanted to volunteer some information we need to understand what the patients are looking from the GSK perspective. We have set up a number for and until we can fundamentally aVect allergy then of long-term academic collaborations with a number we need to treat the consequences of it. We need of the Centres of Excellence supported by the MRC. to treat asthma, we need to treat the broncho- We collaborate with the NHLI, with the Universities constriction, we need to treat the inflammation that of Southampton, Manchester and Edinburgh. These follows it, we need to treat the rhinitis, the watery eye are long-term relationships which, although they are and that sort of thing in hay fever. Obviously to focused around a particular area of research at any deliver those therapies it has got to be very diVerent one time, tend to have a strategic nature because if you want to give them via an inhaler for asthma or these are the Centres of Excellence so the long-term intra-nasally for hay fever. We try and treat the relationship ultimately benefits these sorts of long- consequences of the allergy in the appropriate way term studies as well. and we focus on understanding the consequences and treating it appropriately. To go beyond that and start Q226 Lord Colwyn: I think my question has been to think about how we can fundamentally aVect the answered. I was just finding it hard to work out the course of these diseases, then we need to do research relationship between big pharma and medical into the basic allergy mechanisms, we need to research, and it is obviously closer than I imagined. understand the way that T-cells and the sub- Professor Westwick: Yes. Most pharmaceutical populations of T-cells start to talk to each other. That companies that are in respiratory medicine have is where we collaborate a lot more with academic long-term arrangements with leading academic and centres to do more fundamental research to try and allergy: evidence 85
18 December 2006 Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen and Professor John Westwick progress our understanding long before we can start Q233 Chairman: An area which concerns me is we to apply it in a sense that will fundamentally change have heard in previous evidence there are areas of the natural history of these diseases. rather unglamorous research which need to be done and people have a lot of diYculty in securing funding from anywhere, partly because the pharmaceutical Q229 Baroness Perry of Southwark: So the route you industry has no interest in those areas particularly at go down is much more to look for collaboration with, the moment and because the research funding bodies say, MRC funded research rather than to look at have already committed all their money. I wonder if what they are doing and do something diVerent? you want to comment. That is really more for Mr Allen: It is fair to say that when you look at the Professor Lee, I think. more basic science then the amount of work that we Professor Lee: Obviously it happens. There is no real can bring to bear, even as a huge pharmaceutical solution to that because if the funding is not there to company, is very tiny compared with the amount of do the work then the work cannot be done. basic science that goes on globally, so we look to play Mr Allen: I have doubts about whether the disparity our part and we look to partner and we look to do really exists. If you look at respiratory research and that in collaboration. Where it is applying those learnings in a drug discovery sense that becomes recognise that allergy is only a part of that, a lot of something that we think we are quite good at, so GSK’s funding, for instance, goes into chronic obviously we will try and do that ourselves, but it is obstructive pulmonary disease which is likely to both parts. become one of the world’s top three killers by 2015 to 2020, there is no allergic component, but if you capture that spending under respiratory research it Q230 Baroness Perry of Southwark: Perhaps I could will be a very substantial part of it. I do not think ask our witnesses more broadly, given there is great there is a disparity, generally we partner where we disparity between the amount of money put by have joint expertise, we invest ourselves where we Government into allergy research compared with have unique expertise and I think we would expect what is put in by the pharmaceutical companies the research institutions to invest where they have collectively, do you think there is a danger that unique expertise. pharmaceutical companies might determine the agenda of research? Professor Westwick: Yes, I think that is possible. Q234 Baroness Perry of Southwark: Some of the Dr Dunstan: I was going to answer diVerently research that we have been hearing about this actually. I am not sure what figures you have got but morning into the prevention of the allergic reaction in there is a paper that we received quite recently about the first place, so to speak, to de-sensitise the person, asthma that suggests charities and Government is that something that pharmaceutical companies together invest about the same amount as industry leave to academic blue skies research or are the each year. pharmaceutical companies involved in that as well? Professor Westwick: There are a number of smaller companies that are linked up with larger Q231 Baroness Perry of Southwark: In that one field. pharmaceutical companies. There are a large number Dr Dunstan: In that one field, yes. of immune deviation trials going on right now, I am aware of at least five that are in operation. The whole Q232 Baroness Perry of Southwark: I was talking purpose is to look for a long-term loss of allergic about allergies in the broadest sense. response. Dr Dunstan: I do not think there is any chance that Mr Allen: There are two levels that we need to either of us are going to dictate the agenda. As understand. To fundamentally modify the immune Mr Allen says, we are going to be working together. system has to be a very long-term goal. We should Professor Lee: I agree broadly with what has been said recognise that you do not mess with the immune already but there is one slight problem sometimes system very lightly. It is because of that that I would that arises when a therapeutic manoeuvre developed fully support a strong research base in the UK that by a company is extraordinarily expensive. If the continues to tease out the role of the immune cells, programme of work that the academic community the sub-populations, the way they talk to each other, wants answered is not necessarily within the strategic the way antigen is presented in all of its complexities. direction of the company they may not provide you Where we look at the hope in the near term, which is with the material to study. If it becomes prohibitively to re-educate the immune system not to respond to expensive for academia to pursue, that is one slight grass pollens and tree pollens, there are good clinical issue which can arise from time to time. It does not studies ongoing and it is an area of very active interest happen very often but when it does it is awful. for all the pharmaceutical companies. 86 allergy: evidence
18 December 2006 Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen and Professor John Westwick
Q235 Lord Rea: How does UK funding for research Professor Westwick: I think one of the problems when into allergic disorders compare with other countries? you are talking about respiratory is trying to separate I am talking about all the sources of funding, how much is allergy/asthma because respiratory now Government, charity and industry, how do those includes a very large area within the pharmaceutical compare with what goes on in other countries? companies, but if you just say “respiratory” it is good Dr Dunstan: I do not have the figures for anything to know that within the UK the three leading except respiratory work. In respiratory work, the pharmaceutical companies worldwide have their share of the funding that we have is proportional to respiratory research, which often includes their the share of biomedical funding that the UK has in allergy/asthma research, located in the UK. relation to spend in other countries but in some other areas of respiratory work countries such as Australia, Q238 Lord Rea: Which allergic disorders receive the Finland and Sweden have a significantly greater largest amount of research funding and do you think investment relatively speaking than the UK. this is appropriate? I can foresee that you are going to Mr Allen: From a purely GSK perspective, we have say “asthma” but then we have the problem with the majority of our asthma and rhinitis work based in what part of the asthma research is directed the UK which means we have a disproportionate specifically towards allergy. amount of our spend internally in the UK. We do Professor Lee: I can only speak for Asthma UK. have collaborations in the US and across Europe About 30 per cent of the Asthma UK spend is directly but because our people tend to be here, we related to allergy. collaborate locally with the academics that are here. From a company perspective we are investing disproportionately in the UK. Q239 Lord Rea: That is clear. Professor Lee: I tried to get some information about Dr Dunstan: I do not have those figures for MRC. I spend on allergy/asthma research from a number can get them for you if that would be helpful.1 of diVerent bodies and the information I have is incomplete, nevertheless I have some information. Q240 Lord Taverne: I want to ask you about Sir The NIH was very helpful and wrote back to me and David Cooksey’s recent review. They recommended their spend per annum in the financial year of 2005 that: “greater priority should be given to supporting for asthma and rhinitis alone was £154 million. medicines and therapies that tackle unmet health needs in the UK”. They recommended that the Y Q236 Lord Rea: As compared with the UK of what Government should set up a new O ce for Strategic Co-ordination of Health Research. Do you think sort of figure? Y Professor Lee: Dr Dunstan was telling us about the that this approach will overcome the di culties MRC spend. Away from the MRC, including the which are currently experienced in allergy funding? Wellcome Trust, Asthma UK and a little bit of They also recommend that the Department of Health information from the Department of Health, the should review the impact of diseases and illnesses to amount of money other than Research Councils is in determine the health priorities. Do you think that will the order of £6 million per year. help to establish allergy as one of the health priorities in the UK? Dr Dunstan: MRC spends a bit over £5 million a year Dr Dunstan: We welcome the proposals in the directly on allergy research and £15 million a year on Cooksey report and certainly they will put a major basic understanding of immunological mechanisms, emphasis on collaboration between the money that is some of which would be relevant to allergy. spent through the health departments on R&D and the MRC. Also they will put a major emphasis on Q237 Chairman: Dr Dunstan, could you clarify is translation and exactly how that will work out I am that all allergy and of that amount how much not sure. One of the things they have asked the is asthma and how much is other allergic overarching body to do is to make sure that unmet manifestations? needs are met. When UK Clinical Research Professor Lee: That is the issue. When I tried to find Collaboration looked at areas that they have out information about this, including how diVerent considered were under-funded in relation to research organisations label their funding, it was morbidity, respiratory disease, of which asthma as a complicated. Allergy and asthma tends to be mixed part was one and colitis was another, and I think up. Looking at the portfolios, the ones that I have there is some inflammatory work and allergy related seen from the titles, the majority of those is asthma to that, so they may well fall into the categories of rather than allergy globally and more fundamental unmet need that we shall have to direct more than translational. The numbers are quite startling attention to. really. 1 Please see MRC supplementary written evidence. allergy: evidence 87
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Professor Lee: Let me add to that. I think it is Q242 Lord Taverne: Should they consider allergy as absolutely crucial that we do try to estimate the a single health issue or would it be more suitable to burden of the disease and unmet need in allergy. I do consider the health priorities of the various diVerent not underestimate at all the real diYculty in disorders? capturing that information because at the moment in Professor Lee: No, I think we should consider allergy the Health Service we do not have a structure that as a disease grouping because many patients with allows us to collect that information. When you look allergic problems present with multi-system disease at that burden and unmet need you have to take into and that, in a sense, is one of the rationales for consideration not only the very few people who find establishing a service which allows a one-stop-shop. their way to allergy centres but we also have to take I agree with the previous conversation in the last into account the other patients in dermatology session where allergists also have to contribute clinics, respiratory clinics and so on. When trying to towards looking after severe asthma in a understand unmet need you also have to take into contributory capacity but allergy as a specialty has a considerations estimates of the holistic patient, not very major role to play. just in that specialty. Whilst I very, very strongly support the idea that we should do this, I think collecting the information would be very, very Q243 Baroness Platt of Writtle: There are diYcult but necessary. Probably some resource will certain areas of research which may not necessarily need to be put into that to allow that to happen. That have a precise answer or profitable outcome is my first point. The second point is even if you have but, nevertheless, are of considerable long-term the resource to do that, methodology will have to be importance. For example, we are still not able to developed because although we have methodology provide reliable nutritional advice to pregnant for assessing asthma the suite of methodologies for women or young children to prevent allergic assessing angio oedema, for example, and other disorders. Where should the funding come from to allergic diseases away from asthma are not very well research areas such as these? Dr Dunstan: developed and they may have to be developed to I think the research councils and the really understand this problem in the wider context. charities have a significant role to play. I guess in UKCRC, that has already been referred to, in some of the cases you mentioned we are back to long- respiratory medicine has been a very big driver in term studies with cohorts again. We are doing that, understanding the funding just does not match the and we are getting partnership funding for those: disability, morbidity and mortality of the disease. We ALSPAC, Southampton Women’s Survey. For all suspect, and there is evidence, that allergy is in environmental allergies, I suppose the UK Biobank, exactly the same position but allergy is not just which is looking at a more elderly population, middle respiratory, it is only the tip of the iceberg when you aged onwards, will also provide information. I know, think about asthma. for example, in Professor Lee’s centre there are studies going on about whether children at a high risk of allergies should be exposed to peanuts or Q241 Lord Taverne: You say there are a lot of whatever, and we are currently discussing with the diYculties about it but do you agree that a new Food Standards Agency whether we can jointly fund strategic framework, as they suggest, the OYce for a study on early weaning. I think these kinds of Strategic Co-ordination of Health Research, would studies should give some of the answers that your help to face these problems? questioner needs. Professor Lee: Absolutely. I am very strongly Professor Lee: I very much support that view. I think, supportive of that, and I am very strongly supportive as I said already, partnership is going to be the of the other recommendation of the Cooksey review answer in the future, but I also feel there is a role to which states that the amount of productivity and the play in some of the really big questions which will excellence of the research coming from the funding of involve very large cohorts and will be very expensive basic fundamental science is of such quality that that to adopt a more iterative approach to arriving at has to be at least sustained, and any new money protocols and arriving at a way forward. I think for should go more towards the translation of clinical very good reasons much of the funding strategy is a aspects. Certainly hearing from the UKCRC competitive one and you do obtain very, very good analysis, the vast majority of funding from applications of exceptional quality because of that. Government bodies—MRC; BBSRC Wellcome We all have to go through that system. There are Trust; Asthma UK and so on—tends to be more major opportunities in the future to work together towards the fundamental methodological continuum in partnership in long-term studies on major of the research spectrum, and we need to do more questions which will impact on healthcare where the now to translate those findings into the patient and development of a programme of work on an iterative into the community. basis may be a better way forward. Certainly from 88 allergy: evidence
18 December 2006 Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen and Professor John Westwick our own perspective, a few years ago we worked very Q248 Baroness Platt of Writtle: Are your closely with MRC to develop an iterative programme commercial companies involved in that? to look at the safety of salbutamol in asthma. It took Mr Allen: Insofar as we are trying to understand the us a long time to arrive at that programme but we did response to these allergic triggers, then certainly we arrive at that programme and we did the study which are, yes. was very informative and was published in a very high impact journal and is often used as one of the Q249 Viscount Simon: As allergic diseases involve major studies in this area. I think it can work and we V should do more of it. many di erent genes and exhibit considerable phenotypic variation, what steps are being taken to develop more individualised treatments? Secondly, Q244 Chairman: How much is that iterative process what research is being undertaken to understand the involving the patient population who have the factors which determine an individual’s susceptibility allergic manifestation? to allergic disease? Professor Lee: I think the answer is more and more. Mr Allen: From a GSK perspective, we have the Certainly in one of the consultations we have just objective of taking, with the patient’s consent, blood finished and published, Basic Asthma Research samples from every single patient who is involved in Strategy, and also the one on Clinical Asthma a GSK research and development organised clinical Research Strategy, lay people were involved. In fact, trial, with the objective of genotyping (subject to in February there is a conference at the Royal Society clinical trial outcomes) that patient so that we can of Medicine which I am chairing for lay people. We subsequently look at how that genotype has reacted will be discussing our Basic Asthma Research to the treatment and the outcome, both from a safety Strategy with them in depth. and eYcacy point of view. That is ultimately the goal. We have a very high percentage (60 per cent) of those Q245 Chairman: Dr Dunstan, can you tell us how samples taken now so we can go back and ask very much the MRC will interact with the GA2 LEN careful questions about how certain patients have centres? reacted to the drug that is in the clinical trial in Dr Dunstan: Sorry, with whom? relation to genotype. The other thing we need to recognise is there is a huge phenotypic variation within the allergic diseases. We have heard about Q246 Chairman: With the GA2 LEN centres. 2 severe asthma patients who do not respond well to Dr Dunstan: I am not sure what the GA LEN steroids, who would have a diVerence response, and centres are. we need to understand the clinical phenotypes within Professor Lee The European framework. each of the diseases as well as between the diseases. Dr Dunstan: We interact with European funding We can only do that by good translational medicine quite a lot, whether we interact specifically with these work, by long-term clinical studies, but also by or not, I do not know. We are doing quite a lot of phenotyping these patients very carefully so that we work on quality of life across a variety of diseases on can start to understand their disease long before we those issues. can start to attempt to cure it or even modify it. Professor Westwick: It is very similar studies that have Q247 Baroness Platt of Writtle: What about been going on in Novartis as well. Again, we like to research into other lifestyle issues, such as the impact identify the phenotype and the genotype. Indeed, a of pollution on allergic disease? Who is carrying out number of papers have been published in the last four research into that? years which were thought to identify the genes Dr Dunstan: I think pollution may be one of the issues responsible for asthma, but on reproduction which comes out of the UK Biobank study and other elsewhere that does not seem to be the case. To say long-term cohorts. It is fair to say that the research that we know the genetic basis of asthma right now is councils, NERC, ESRC and MRC, are looking probably wrong but we may get to it. The second part again under a broad heading at what we call of your question, can we modify the environment so “environmental health” and pollution will form a that the allergic responses are removed, goes back to part of that. It will be one of the bids which goes the first thing I was talking about where we and many forward jointly from the research councils into the others believe that how the specialised dendritic cells spending review this time. within the airways respond to the environment in the Mr Allen: Of course environmental triggers are one presence of a specific antigen and various T-cells is of the things which attract a lot of research at a basic the key to regulating that. For that reason, we scientific level, things like ozone and particulate and others have developed agents which modify matter that will trigger asthma responses do feature particular receptors on these dentritic cells to deviate very largely in academic research. the response away from our allergic mechanism. allergy: evidence 89
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Q250 Lord Colwyn: Are there any populations of Q252 Chairman: There may be some analyses individuals anywhere in this country or elsewhere though that can be done which fall outside the main who are particularly susceptible to allergic disorder trial protocol. How much freedom do researchers through inbreeding and inter-marriage? have to proceed and publish those when they are in a Professor Westwick: Indeed, that is where the genetic drug company funded study? basis of asthma came from, from these inbred Professor Westwick: I think most academic and populations. The problem is when you move to wider clinical centres worth their salt will not get into an populations it does not seem to hold true in terms of agreement with a pharmaceutical company unless the identity of the gene which was found in those they can publish the work they are doing. studies. Professor Lee: This is an incredibly important area Q253 Lord Taverne: What is the panel’s view of what and it is also an area where I think collaborations currently are the most important areas of research, between the universities, academia and industry and who is undertaking these? should flourish because industry does so many Mr Allen: How long have you got! pharmaceutical trials. They have a readout in a very Professor Lee: Let me start because I am going to give detailed and well designed way of the responsiveness you an answer which will seem a little vague but, of individuals to certain drugs. We know that the nevertheless, I want to refer you to four documents distribution and response to drugs follow a certain and that is really my answer because we have been pattern and some respond very well, others do not. through this in some detail and they have been To be able to have all the blood samples genotyped submitted to you in written form. First of all, the and be able to link that to treatment responsiveness most recently published document on Basic Asthma is very, very powerful. That has been used, especially Research Strategy, which we lovingly call BARS in the United States, to look at a number of diVerent Version II, was published only a few months ago. questions, including the eYciency and safety of beta- That sets out a number of priority areas with key agonists, for example. I think the pharmacogenetics questions which we feel we should answer in the eVort, which is what this is, at the NIH is probably asthma area. It is multi-professional involving many very strong as a result of this sort of collaboration funding bodies in that consultation. Then about two and probably more advanced than what we have in or three years ago there was a similar consultation on this country. This is not just an academic question Clinical Asthma Research Strategy which has because the regulatory authorities in the future will already been published. Some of the issues raised within that consultation are part of the Health demand to have this sort of information when you Technology Assessment exercise and have been are registering your drugs and that is a very powerful funded to some extent by the Department of Health, driver to do this sort of work. so, again, that is already in the public domain. The Professor Westwick: I would agree with what third is a letter which Professor Durham wrote to you Professor Tak Lee was saying, but one has to keep in as part of his written submission on what the British mind that most of the studies in asthma and allergy Society of Allergy and Clinical Immunology believes have shown that these are polygenetic diseases, they the research priorities should be. are not monogenetic, like cystic fibrosis. It is a very complicated sector involving a number of genes as Q254 Lord Taverne: This is the one we have got, is it? well as an environmental influence. Professor Lee: Yes, that is the one you have.
Q255 Lord Taverne: The recent one, British Society Q251 Chairman: Who is responsible for publishing of Allergy and Clinical Immunology? negative results? Professor Lee: Yes, so you have that information. The Mr Allen: The results of all clinical trials have to be fourth document I will refer you to is a document published.2 published by the Department of Health entitled, 2 GSK publicly discloses the results of GSK-sponsored clinical “A Review of Services for Allergy: The Epidemiology, trials that are relevant for patient care irrespective of whether the demand for and provision of treatment and results are positive or negative for GSK prescription medicines eVectiveness of clinical interventions”. That review, or vaccines. Whenever possible, public disclosure is via publication in apart from many things, covered and highlighted scientific peer-reviewed publications. In addition, GSK provides parts of the research evidence from the health service clinical trial results via the GSK Clinical Trial Register [http:// point of view. ctr.gsk.co.uk/welcome.asp]. Here, GSK provides the results of all trials (phase I-IV) of marketed prescription medicines and vaccines. GSK will also post trial results of investigational Q256 Lord Taverne: Is that the document of which medicines and vaccines that do not make it to market when relevant to patient care (eg, when related to an important Professor Durham and Professor Frew said: “It gives safety issue). no grounds for optimism”? 90 allergy: evidence
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Professor Lee: That is correct, that is it. They were Q260 Lord Taverne: What new products are being referring to the development of the health service developed which could have a significant impact on framework and health service delivery, but the issues the treatment of allergic diseases over the next five which that document raised about health services’ years? research required to provide the information base to Mr Allen: I guess the first point is five years is a develop future strategy I think are very intuitive. In very, very short time period in drug discovery; my answer I will refer you to those four documents, unfortunately it is more like 15 years to turn basic if I may. research into a product and take it through all the regulatory requirements. Q257 Chairman: Can I go back slightly to the previous question. If each company has very rich Q261 Lord Taverne: Which end of the last five years data on genotype and phenotype, is there a move to of the 15 year period? produce a pooled Disease Registry so that all this Mr Allen: I will not talk about that, I will leave that information can be shared and avoid duplication and to someone else. There are some very interesting also allow further research projects to be built on the developments going on in the way that the basic information which is held? immune cells talk to each other and the way they Mr Allen: I have to be careful because I am not expert respond to diVerent antigens because this is all about in this sort of area. I do know that a very important inappropriate immune response. This is not about consideration is the consent given by patients when immuno-suppression, we are not talking about they are involved in a clinical trial. You have to be suppressing the immune system, we are talking about very, very explicit about what the samples would be teasing out some very subtle whispering that goes on used for, who would have access to them, and to what amongst these immune cells. We know the sub- purpose they would be put. Research undertaken is populations of immune cells which seem to be restricted by the scope of the written consent. It is a very important part of any governance of clinical responsible for a lot of the chemical messengers and trials. The only thing I would be cautious about is we inflammatory mediators which are now associated must therefore only do with these samples exactly with allergy in its broadest form and we are starting what we have told the patients we will do with them to find mechanisms to impact those in a very, very but, of course, the sharing of information and specific way. I do not think they are going to do it collaborating with all of this information is in with medicines in the next five years, but I think over everybody’s interest. the next five years you are going to see early clinical trials on mechanisms which do talk to these very small populations of T-cells being modified in very Q258 Chairman: Of course you cannot do anything specific ways. That really will be the next generation with the samples you have got other than what the of therapies for allergy. consent has permitted, but I was wondering whether Professor Westwick: I agree with what David said. In there are moves to establish a pooled Disease terms of what is going on now, you have already Registry with consent in future studies then ensuring heard about Xolair, the anti-IgE which came out that those patients could be involved and registered from the laboratories of Genentech. There are also a on a central Disease Registry rather than each centre lot of other antibodies out there now in clinical trial having its own much smaller cohort of patients? for asthma and allergy, antibodies directed against Professor Westwick: The requirement of published various cytokines and these are small proteins that clinical trials and to register that should provide that are involved in this allergic response. They are in information for everyone to look at, whether it be another pharmaceutical company or not. I think you proof of concept or Phase II (b) studies right now, so are going one stage further where all basic it will be another three to four years before they will information that is generated, which may not be be registrable. generated from clinical trials but from some sort of analysis of databases which are either in the public Q262 Lord Taverne: Is there a prospect of a domain or the private domain, that comes out of that successor drug to Xolair which would be cheaper is going to be publicly shared. I do not think we are because I gather it is very, very expensive? there yet. Professor Westwick: Yes. First of all, if you look at all diseases and all pharmaceutical approach, the use of Q259 Chairman: Professor Lee, have you got any antibodies is increasing dramatically. It used to be all comments? the small molecular weight compounds but if you go Professor Lee: No, except that if that database was into all diseases, antibodies are increasing and available it would be extremely useful. particularly so within allergic mechanisms. The cost allergy: evidence 91
18 December 2006 Professor Tak Lee, Dr Diana Dunstan, Mr Dave Allen and Professor John Westwick of antibodies and the work involved in getting to the Chairman: I think we are at the end of our session. state you need is much more than it is with the low Could I thank you very much for coming today. molecular weight agents. However, having said that, Also, if there are additional points you would like to I think where antibodies are also being used is first of make to the Committee, we invite you to send them all as a proof of concept that that particular target is in writing to us. We will be sending you a transcript important. A lot of companies are following behind of the session for you to correct for accuracy. Thank with some low molecular weight equivalent which you very much again and thank you also for the can be usually much cheaper to produce and will papers you submitted to us, particularly Professor come out two to three years later. Lee.
Supplementary memorandum by the Medical Research Council
1. Which allergic disorders receive the largest amount of research funding from MRC, and do we think this is appropriate? Asthma is the allergic disorder that receives the largest amount of research funding from MRC. We believe this is appropriate because asthma is a major and growing health problem. Furthermore, we receive applications in response-mode, and this is the field in which there is the largest critical mass of expertise in the UK. Much of the research classified as asthma research will have potential for wider applicability to allergy (see below). Other allergies which the MRC currently supports are dermatitis and allergy to antibiotics.
2. How much does the MRC spend on asthma research, and how much of this is directed specifically towards allergy? It is not easy to distinguish research on asthma that is unrelated to other allergies, or research on allergy that would be unrelated to asthma, especially in basic research (eg genetic predisposition, understanding immune responses etc). According to the way we have categorised our projects, for the five years 2001–02 to 2006–07: — our total spend on asthma research was £15.7 million. — Our total spend on general research was £13.0 million (this includes research into known cellular components of the allergic reaction, how the allergic reaction is induced, signalling pathways in the allergic reaction compared with the reaction to infection, aspects of vaccine design and stimulate allergic responses, molecular regulation of cytokines genes known to be involved in allergic reactions, the molecular structure of molecules in the lgE network, and some aspects of nutrition and allergy). — Our total spend on other allergic diseases was £2.1 million. (this includes eczema, dermatitis and allergy to antibiotics). These figures are mutually exclusive, but for the reasons given above should not be over-interpreted. 92 allergy: evidence
WEDNESDAY 10 JANUARY 2007
Present Broers, L Platt of Writtle, B Colwyn, L Rea, L Finlay of Llandaff, B Selborne, E (Chairman) Simon, V May of Oxford, L Soulsby of Swaffham Prior, L Perry of Southwark, B Taverne, L
Letter from Professor Anthony Newman Taylor CBE, Head of National Heart and Lung Institute, Faculty of Medicine, Imperial College, London Thank you for inviting me to submit evidence to your committee’s inquiry into Allergy. I will focus on occupational asthma because it is the most important of the occupational allergic respiratory disease and the one in which I have most experience. Occupational asthma, is asthma induced by an agent inhaled at work. This may occur in one of two ways: 1. The inhalation of an irritant chemical, such as chlorine or sulphur dioxide, in concentrations toxic to the lining cells of the bronchial airways. This causes an acute inflammatory reaction with local injury in the airways, which in a minority of cases is followed by the development of chronic asthma. 2. The development of a hypersensitivity reaction (allergy) to an inhaled protein or low molecular weight chemical. Proteins which may be inhaled at work and cause asthma include enzymes used in the detergent and baking industries, proteins excreted in the urine of laboratory animals—rats, mice, guinea pigs—and proteins in flour encountered in bakeries. Low molecular weight chemicals, so called “chemical sensitisers”, inhaled at work include isocyanates, used in the manufacture of polyurethane plastics and polyurethane spray paints, acid anhydride used in the manufacture of epoxy resin, plastics and paints and complex platinum salts, essential intermediates in platinum refining. Of these two, hypersensitivity induced (or allergic) asthma occurs considerably more frequently than irritant induced asthma. Occupational asthma is the most frequent category of occupational lung disease reported by chest physicians and occupational physicians to the voluntary reporting scheme, SWORD (Surveillance of Work and Occupational Respiratory Disease). The total number of cases of occupational asthma reported by SWORD has fallen during the past decade, primarily due to a reduction in the number of cases reported by chest physicians between 1999 and 2000. The number of cases attributable to isocyanates is now less and the increase in the number of cases caused by latex allergy has decreased since the widespread use of low protein non-powdered rubber gloves. However, a similar decline has not occurred in the number of cases attributed to flour in bakery workers. It has been estimated by a panel of the American Thoracic Society about 15 per cent of asthma in adult life (ie one in seven) is attributable to an occupational cause. Occupational asthma is distinguished as a type of asthma by being potentially preventable and, in many cases, curable. Several studies, undertaken by diVerent groups in the 1990s, showed that the major risk factor for developing occupational asthma, caused by allergy to an agent inhaled at work, was the level (concentration) in air of the specific agent in the place of work. This was demonstrated in studies of enzymes in the detergent industry, animal urinary proteins in the pharmaceutical industry, flour and enzymes in the baking industry and acid anhydrides in the chemical industry. Prior to this, allergic occupational asthma had been considered as a consequence primarily of individual susceptibility. The important implication of evidence for an exposure—response relationship is that the incidence of occupational asthma should be decreased by reducing the level of exposure to its causes in the workplace. This has now been demonstrated in studies of enzymes in the detergent industry, of latex in health care workers and of isocyanates in Ontario, Canada. Comparable interventions now need to be extended into other industries in order to make further impact on the overall incidence of the disease. Because occupational asthma in the majority of cases is due to the development of an allergy to an agent inhaled at work, to provide the best opportunity for asthma to improve and in some cases resolve it is, in general, important to avoid further exposure to the responsible agent. There is consistent evidence to indicate that early diagnosis and avoidance of exposure to the cause of allergic occupational asthma provides the best allergy: evidence 93
10 January 2007 opportunity to prevent the development of chronic asthma. It is therefore important to provide services which enable an early and accurate diagnosis of occupational asthma. Of similar importance mis-diagnosis of a case of occupational asthma, ie attributing asthma incorrectly to an occupational cause, can lead to inappropriate advice to leave work often it is diYcult for individuals to get back into the labour market, with important financial and social consequences. There is therefore an important need to provide specialist services within the United Kingdom, to which possible cases occupational asthma can be referred, in order that an accurate diagnosis and informed advice about future employment can be provided. The number of such specialist centres does not need to be great, probably no more than half a dozen throughout the United Kingdom. They are an important resource for the specialist management of a disease which requires understanding of respiratory illness and the hazards of work as well as the provision of well-informed advice about future management. Unfortunately in many cases the only way to avoid expose to an allergic cause of asthma is a change of job, which can mean the loss of employment. There is evidence from a number of studies that those who leave their job because of occupational asthma can remain out of work for several years; they seem less likely than other asthmatics of a similar age to obtain new employment. There is a real need to provide the means to support re-training for individuals with occupational asthma, with facilitation into new jobs. This could be a function of the Industrial Injuries Scheme, which provides compensation for occupational asthma as a prescribed disease. Unfortunately, since the withdrawal of Reduced Earnings Allowance in 1990, this opportunity is no longer available under the scheme. Review of the Industrial Injuries Scheme, with a view to reforming it, is currently under way. The introduction of a benefit which could support and enable re-training of individuals unable to continue in their current job because of a prescribed disease, such as those with occupational asthma, to enable them to remain in or return to work should be an important function of a reformed scheme. 20 November 2006
Memorandum by Professor Raymond Agius, Professor of Occupational and Environmental Medicine, and Director of the Centre for Occupational and Environmental Health, The University of Manchester
SUMMARY PREPARED IN RESPONSE TO SOME POSSIBLE QUESTIONS ON OCCUPATIONAL ALLERGY (DERMATITIS, ASTHMA AND RHINITIS) Data from SWORD (Surveillance of Work Related and Occupational Respiratory Disease) and OPRA (Occupational Physicians’ Reporting Activity) up to 2005 inclusive shows that certain occupations present a particularly high risk to UK workers of developing occupational asthma, notably bakers, confectioners and others exposed to flour (amongst whom allergic rhinitis is also common), and vehicle spray painters exposed to isocyanates, although risks are widespread in many occupational sectors. Dermatitis in the UK as reported through EPIDERM is widespread and exhibits the highest incidence amongst hairdressers and beauticians, although in absolute numbers reports in nurses tend to be greater since they constitute a larger occupational group. Although occupational asthma accounts for only about 15 per cent of occupational disease cases reported to the University of Manchester by respiratory physicians (SWORD) (the majority of cases still being asbestos related), the situation is reversed in reports to us from occupational physicians (OPRA) from whom occupational asthma reports account for the majority of occupational lung disease. Occupational dermatitis is by far the commonest occupational skin disease reported to us by dermatologists (EPIDERM), occupational physicians (OPRA) or GPs (in The Health and Occupation Reporting Network for GPs: THOR-GP) but diVerentiation between allergic and irritant cases is not always easy especially for non-specialists. The HSE recognises that there is substantial under-reporting of ill health through RIDDOR (the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) and 2002–03 was the last year for which RIDDOR ill health reports were compiled into its summary statistical tables. The data from SWORD, OPRA and EPIDERM up to 2005 inclusive are consistent with statistically significant reductions in reported incidence both of occupational asthma and occupational contact dermatitis. However caution has to be expressed because of potential artefacts, and also the presence of diVerential trends depending on causal agents or exposures. Thus for asthma there appears to have been a persuasive fall in reports of latex asthma yet for asthma caused by flour no such trend is apparent. Glutaraldehyde asthma reports also appear to have fallen; but we have concerns about sporadic reports associated with its substitutes, as well as evidence from our other research based on their chemical structure suggesting that some of these may also present an asthma hazard. 94 allergy: evidence
General Practitioners generally receive hardly any training regarding the recognition or prevention of occupational allergic diseases, and they probably tend to treat asthma, rhinitis and dermatitis in a similar way regardless of cause. However courses such as the Diploma in Occupational Medicine are available to them on a short course or distance learning basis. Our data mainly from ex-alumni of ours who have attended the latter suggest that these GPs, who participate in THOR-GP, refer about one quarter of the suspected new cases of occupational asthma and occupational dermatitis to specialists, mainly to chest physicians and dermatologists respectively, but occasionally to occupational physicians. Analysis of the reports in our growing database, by industry sector and especially by temporal trends should permit us to continue to identify high risk exposures and to evaluate the eVect of control strategies on trends in incidence. Moreover research such as ours relating chemical structure to allergic hazard through Quantitative Structure Activity Relationships (QSAR) can help predict novel hazards. Acknowledgements: EPIDERM, OPRA, SWORD and THOR-GP are constituents of THOR (The Health and Occupation Reporting Network) which encompasses the occupational surveillance and research schemes of the University of Manchester: http://www.medicine.manchester.ac.uk/coeh/thor/ Data collection through EPIDERM, SWORD and OPRA was funded by the UK HSE until 31.12.2006. Data collection through THOR-GP is funded by the HSE until November 2008.
Examination of Witnesses Witnesses: Professor Anthony Newman Taylor, Chairman, Industrial Injuries Advisory Council, Mr Rob Miguel, Health & Safety Officer, Amicus the Union, Professor Raymond Agius, Director, Centre for Occupational & Environmental Health, University of Manchester, and Dr David Orton, Consultant Dermatologist, Amersham Hospital, Buckinghamshire, examined.
Q263 Chairman: Can I thank our witnesses for Advisory Council which advises the Department of coming today. I am Lady Finlay. I am chairing this Work and Pensions on the Industrial Injuries select committee inquiry. There is an information Disablement Benefit Scheme. note with all the declared interests of members of the Committee so we will not be going round declaring our interests during the evidence session today, but it Q264 Chairman: Thank you. Perhaps I could start is available for members of the public. We are most with a question which I would like you all to try and grateful to you for coming today. Professor Agius, answer. We have a lot of questions that we want to you have sent in a document which we have now get through with you today so it is helpful if you can circulated to the Committee. I wonder if you could keep your answers concise so that we can get through introduce yourselves briefly. all the topics we want to cover. Which occupations Dr Orton: Good morning. I am Dr David Orton. I am present the highest risk to workers of developing a Consultant Dermatologist at Buckinghamshire conditions such as occupational asthma, dermatitis, NHS Trust with an interest in contact dermatitis and rhinitis and other allergic diseases? occupational dermatitis generally. Dr Orton: My Lord Chairman, as a dermatologist I Professor Agius: My Lord Chairman, I am think I had best restrict myself to dermatology but I Raymond Agius. I am Professor of Occupational would say that the largest groups in occupational and Environmental Medicine at the University of practice that we see with skin problems are from Manchester and I am Director of the Centre of the healthcare sector, healthcare workers and Occupational & Environmental Health there which, hairdressers. It really depends on how you examine amongst other things, collects data on occupational the data. If you look at point-prevalence cross- and work-related disease. sectional studies amongst certain occupations or you Mr Miguel: My Lord Chairman, I am Rob Miguel. I look at the data submitted by medical practitioners am the Health & Safety OYcer at Amicus, which is a to organisations such as EPIDERM, generally trade union with 1.2 million members representing speaking, fairly consistently across Europe and quite a few sectors in the UK. I deal with general Australia and the United States certain groups such practice and I serve on a number of government as healthcare workers and those in hairdressing, as committees. well as those exposed, obviously, to sensitisers in the Professor Newman Taylor: I am Professor Anthony plastics industry and the construction industry, are Newman Taylor. I am a Consultant Chest Physician going to be represented fairly consistently. at Brompton Hospital. I am the Head of the National Professor Agius: I would agree entirely with what my Heart and Lung Institute and the Department of colleague has said. I think one also has to bring the Occupational and Environmental Medicine there, matter of denominators into account, so while I and I am also Chairman of the Industrial Injuries would agree with him that one tends to see more cases allergy: evidence 95
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton reported to us from amongst healthcare workers, employment law, frustration of contract, where if a of course they constitute a large proportion of worker is deemed not to be able to do his job then he the working population and if we took their can be laid oV by his/her company. This is going to denominator into account then the risk amongst, say, account for quite a bit of under-reporting. Also, the hairdressers and beauticians is about 10 times higher occupational health system relies upon GPs within than the risk amongst healthcare workers, because of the system, and they do not actually feed into the course there are fewer hairdressers and beauticians. reporting. I understand from HSE that they are So we might see in the order of three per thousand looking at inviting GPs to become involved in the hairdressers per annum reported to us by specialists reporting system. I have some more to say but I know and there is only one tenth that rate for nurses. Of you want the answer to be concise so I will leave course, if one looks further down the pyramid one that there. has to bear in mind that the reports from specialists are only a proportion of the cases seen by GPs, Q265 Chairman: Bring that in later. perhaps one in four, so the pyramid then gets wider Professor Newman Taylor: In terms of occupational and wider at the base and it is diYcult to measure at asthma, the most common group is spray painters. the base. There are then plastic workers, chemical process Mr Miguel: I have been looking at the figures workers, bakers and laboratory technicians that produced by HSE, and hairdressers in relation to constitute the highest incidence, as far as we are dermatology is the highest group followed by aware, of occupational asthma, and then healthcare chemical workers, but these figures could be workers. I would add to what has been said that that confusing because there are other factors to be taken is based upon the reporting by consultant specialist into account. For example, there is an amount of chest physicians and occupational physicians, and so screening which goes on which screens out workers therefore, in order for us to be aware of those cases, who may be susceptible to asthma. There are other they need to have been seen by a specialist chest reasons to believe that these figures are accurate but physician in the case of asthma or a dermatologist in not completely accurate. The figures I looked at came the case of dermatitis, and clearly a significant from EPIDERM for dermatitis and from SWORD proportion of cases does not get there. In terms of for occupational asthma—moulders, core makers occupational physicians, it is worth appreciating that and die casters. I do not know if you know what those it is estimated only about 12 per cent of the workforce occupations are but primarily moulders and core is covered by an occupational physician; therefore makers are producing things like taps and boilers and the opportunity for them to report cases is going to they are cast in a die. Secondly on occupational be relatively small. We did a study trying to estimate asthma, if you take other figures into account spray both the numerator and the denominator for painters come out the highest figure. If you look at laboratory animal allergy and came to the conclusion things like industrial injuries’ disablement benefit that in relation to the SWORD data the numerator information from occupational health physicians the was higher and the denominator was lower and so the figures come out slightly diVerent. I will say though true incidence was higher, but these are the major that there is quite significant under-reporting in causes. dermatology and in occupational asthma. You only have to look at the example of Powertrain, where Q266 Chairman: Can I just ask you how many do they had a massive outbreak at Longbridge. There you estimate have got multiple allergies? were 101 cases reported. Eighty seven of those were Professor Newman Taylor: When you say “multiple of occupational asthma, 24 of alveolitis. If you look allergies”, multiple allergies to both agents they meet at the figures and I give you a figure per 100,000 in the general way as well as at work? workers of 96 for paint sprayers, if I do that calculation in Powertrain alone the incident rate per Q267 Chairman: I was thinking about patients who 100,000 workers would be 4,000, and you can see would be going round diVerent specialist services there is a significant diVerence, so there is a lot of because their allergies manifest in diVerent ways. under-reporting that goes on. However, I have sat on Professor Newman Taylor: I would have thought that a board with HSE which looks at occupations and at that is a minority, because the reality is that although anomalies, and they roughly came out with the same there are overlaps in terms of what causes dermatitis sorts of figures, so for occupational asthma it is and what causes asthma, the two tend to be fairly people in engineering, paint sprayers, people in separate. confectionery, flour, and with dermatitis it is Dr Orton: There is just one point that needs to be hairdressers. Even when you look at all the clarified from the outset, which is that although anomalies, the highest occupations still come out the occupational skin disease is extremely common and same. Part of the under-reporting is due to UK may be due to contact dermatitis, there are, of course, 96 allergy: evidence
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton two sorts of contact dermatitis—irritant contact year-on-year reduction of about 3 per cent, whereas dermatitis and allergic contact dermatitis, and the amongst occupational physicians with skin disease it majority of cases that primary care physicians, or might be of the order of 10 per cent. For respiratory indeed consultant dermatologists, might end up physicians reporting occupational asthma and seeing will be irritant contact dermatitis, but often occupational physicians reporting occupational cases are complex and involve both irritant and asthma there are suggestions of a significant trend allergic factors and that the diagnosis of allergy needs year-on-year to the order of seven per cent. Having to be teased out in order to help with the management said that, one has to exercise caution because even of that specific patient. though we are using the best statistical methods to take into account possible artefacts, such as doctors getting tired of reporting and so on, it cannot be Q268 Lord Taverne: How has the pattern changed? conclusively said that we have got rid of all of those. In Professor Newman Taylor’s letter he mentions Professor Newman Taylor has said that the pattern is that there are now fewer reported cases of certain very patchy within the various causes, so, sadly, kinds of asthma, that there is no change, as far as one for occupational asthma caused by flour, which can see, in the case of bakery workers, and that the arguably, subject to correction by Professor Newman increase in latex allergy has decreased. What is the Taylor, is probably the oldest known cause of cause of the change? occupational asthma dating back a few hundred Professor Newman Taylor: Maybe I can start with this years, there has been no change in that. As Professor and Professor Agius, who is particularly familiar Newman Taylor has said, insofar as latex and with the data, can follow. What has happened since glutaraldehyde over the last three or four years we do the reporting scheme started in the late 1980s is that not get more than 10 specialist reported cases per there has been a fairly consistent number of cases annum and yet for some of the commoner and big reported and the causes of those cases have been causes the problem still persists. fairly consistent. Overall there has been a decline in the number of cases reported due to isocyanates. It remains the most frequent cause, but the number of Q269 Chairman: Are there actions that should be cases reported has declined. There was the epidemic being taken to decrease the incidence? You cited the caused by latex in the 1990s, particularly in change in latex gloves. Are there other things we healthcare workers, with a marked increase and should be doing to minimise or even possibly subsequent reduction following the introduction of eliminate risk in some of these groups of workers that non-powdered low protein latex gloves. There has are just not being done at the moment? been an overall reduction in the number of cases Mr Miguel: Yes, more could be done in the way of which seems to have occurred in one year so that it identifying sensitisers and putting in the appropriate has been about flat, come down and then been controls, but as well what you have to remember is reasonably flat again. There have been changes but that in the UK the structure of the workforce is overall, the incidence of the disease and the causes changing. I had some figures from our personal which are being reported, with the particular injury lawyers. We have 134 dermatitis cases and 102 exception of latex and the reduction in isocyanates, occupational asthma cases and those occupations has not been that dissimilar during the period of come from engineering and manufacturing. The UK reporting. is changing to service based industries so therefore Professor Agius: As Professor Newman Taylor has you are going to find a decrease in the reported said, the situation is rather complex. There are many incidence. factors which militate against getting the highest quality data. One is that to a great extent what we get Q270 Lord Soulsby of SwaVham Prior: With respect is collected from specialist doctors reporting to these various conditions that are being discussed in voluntarily. We have recently, in response to a point this question, is the fundamental immunological made by Mr Miguel, started collecting data from GPs response the same in them all, starting with as well. If one assumes a linear trend, and of course sensitisation of a delayed character and then moving there are lots of reasons why that trend might not be to an acute response, or are there diVerences with the true one, and takes into account as far as one asthma, dermatitis, rhinitis and other allergic possibly can factors like the fact that doctors might conditions? I am wondering if there is a unity there. get tired of reporting and so on, then if pushed I Professor Newman Taylor: If I can answer the question might say that we have found significant year-on- particularly in relation to asthma because the year reductions but the extent to which the reductions underlying immunological response in relation to are manifest varies slightly by the reporting group. dermatitis is diVerent. In relation to asthma, what we For example, amongst dermatologists reporting can describe as allergic asthma, fulfils the criteria of occupational respiratory disease we tend to see a a hypersensitivity response: it develops in a minority allergy: evidence 97
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton of people who are exposed; it occurs after a latent Professor Newman Taylor: I can try and start to interval, and those aVected react to levels of exposure answer that question. The important thing that needs which are much less than cause problems in other to be understood is that the best evidence which we people. So it fulfils the criteria of an allergic reaction. have, and it is now quite consistent in relation to a But it is only in a minority of the cases we can identify number of diVerent causes of occupational asthma, a specific immunological response in the usual way by and I am focusing now on asthma, is that the risk finding IgE in the blood. We can do that for almost of developing the disease is predominantly a all of the protein causes of occupational asthma but consequence of the level of exposure to the agent for chemicals it is only in a minority of causes. We can which causes it. The higher the exposure in general, do it for acid anhydrides, for complex platinum salts, the greater the risk of the disease developing. If the and for a minority of cases of isocyanates. So for incidence of the disease is going to be reduced what many of the causes one cannot identify evidence of a needs to be focused on is a reduction in the level of specific immunological mechanism, although the exposure to its cause, be it urinary proteins from character of the disease is the same as in those in laboratory animals, flour and enzymes in bakery, et which we can. cetera. There have been two good examples where Dr Orton: Again, with allergic responses in the skin control measures have been taken that have made a there are two distinct processes that can result in skin significant diVerence to the incidence of the disease, problems. There is an immediate type of allergic virtually eliminating it. One is enzymes in the response which is predominantly what we have seen detergent industry and the second is latex. In the very frequently with latex proteins in gloves, and then detergent industry, which caused major problems there is the delayed hypersensitivity reaction when powdered enzymes were added to detergents in involving a diVerent immunological mechanism that the late 1960s, it caused problems not only in the results in dermatitis. It is the basis of the latter which workforce but also in consumers. The way this was we use in the diagnosis of allergic contact dermatitis got round was to encapsulate the enzymes in with our patch testing technique. granules, which were too large to be suspended in the air, so they fell out of it and could not be inhaled. One Q271 Lord Soulsby of SwaVham Prior: Where there has to recognise that there was a solution there which is a delayed response will that always be a delayed was possible, as indeed with latex because it was the response or will it change to an immediate response? powder which the protein from the rubber was Dr Orton: No. It usually is delayed. There is a rare absorbing that was getting into the air and being exception when exposure to certain proteins can inhaled. By providing gloves with low protein result in an immediate type of response which, after content in the rubber and which were not powdered a prolonged period of time, evolve into a dermatitis latex allergy could be virtually eliminated. That is a and we see that certainly in certain food handlers much more diYcult thing to do in many other such as sandwich makers, this is described as protein circumstances, but the principle is the same and we contact dermatitis. need to see how we can apply it. The principle is more diYcult, for instance, with laboratory animal urine Q272 Chairman: Professor Agius, could you confirm proteins because you cannot really granulate an to me that the general practitioners’ Quality animal, you cannot granulate its urine. We need to Outcomes Framework does not specify allergic find ways in which we can prevent the urine deposited occupational diseases? on the dust in the cage getting into the air and being Professor Agius: to the best of my knowledge, my Lord inhaled, but it is more diYcult. The second problem Chairman, it does not. is that these two examples are in large employers. The enzyme detergent industry employs many people. Q273 Baroness Perry of Southwark: My question is Procter & Gamble, Unilever, many others, are about the role of the Health & Safety Executive. big companies employing occupational health When they gave evidence to us they said that they physicians and safety advisers and are able to were currently making eVorts to reduce work-related implement on a large scale these sorts of changes. As allergies by raising awareness. They have got schemes Rob Miguel has said, the problem we have now is such as National Hairdressers’ Day, which is aimed with an industry that increasingly is moving from at raising awareness about dermatitis. Do you think manufacturing to service, with smaller workforces, schemes such as this will reduce the incidence of smaller factories and more self-employed people. occupational allergic diseases and what else do you That is a much more diYcult problem. Hairdressing think the Government should be doing to ensure that is, generally speaking, in relatively small outlets employers, staV and health and safety personnel are where there are relatively few people who are aware of the number of agents known to cause working, so there is greater diYculty in finding ways occupational allergic diseases? to ensure they work in a safe fashion which reduces 98 allergy: evidence
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton the risk of disease developing. The answer is that the and we approached a television company to put a type of program the Health & Safety Executive is storyline on prostate cancer in a very popular doing is welcome because it is raising awareness. It is television programme which came out on a Sunday. also hopefully going to be backed up by informed That had a very positive eVect and I did suggest that discussion with employers about what the risks are if you are looking at hairdressers, who are very and how they can be reduced, but the diYculty for the diYcult to reach, and I know it sounds silly, but Health & Safety Executive in this sort of workforce is maybe to have a storyline in Coronation Street where that it is very diYcult to enforce regulations. It is they have got a hairdressing shop. That would reach much easier to enforce at ICI than it is in a local more people than just sending out a couple of leaflets. hairdresser and to my way of thinking this is the real This is the type of thing that needs to be done to back problem and we need to look at means to persuade up these sorts of campaigns. employers that it is in their interests to ensure safe working conditions. That is, I believe, what we need Q274 Chairman: Have you approached Coronation to look at now. There has been some recent research Street? looking at the costs of occupational asthma, which is Mr Miguel: We have not yet. quite considerable in terms of people leaving the Chairman: It sounds like a job for tomorrow. workforce, loss of productivity, benefits paid, et cetera. The great majority of the costs falls on the Q275 Lord Soulsby of SwaVham Prior: Under the individual and on government and a relatively small 2002 Control of Substances Hazardous to Health proportion on the employer, so at the moment those regulations which have recently been revised sorts of incentive are not really there. employers are required to ensure that exposure to Mr Miguel: My Lord Chairman, I agree with substances that may cause asthma or dermatitis is everything that has been said there, especially about controlled. Does this in fact work eVectively? Is it a the fragmentation of the workforce; there are a lot of problem for employees to ensure that the workers are small workforces out there. These sorts of campaigns not exposed? Are there always additional substances V are very e ective as long as they are run in that come to light that may be problematic? combination with the workforce through trade Dr Orton: Only if it really happens. Education and unions and employers. One of the HSE boards, the legislation can achieve only so much. I would like to Disease Reduction Programme Board, has been set revert quickly to the last question in the sense that if up to get all these people together, trade unions, you target your audience and your trainees, for employers, medical people, and look at these example, in the hairdressing industry, evidence from deliveries. For example, in the Powertrain incident, Europe does suggest that you can reduce the and that is a major company, they did not actually incidence of occupational skin disease. That is know what the sensitiser was there, so consequently mainly, I suspect, irritant contact dermatitis, but as I people were sensitised and disease occurred, so it is keep saying, with dermatitis it is often complex and not just occurring in small companies; it is also there are both irritant and allergic factors playing a occurring in large companies because they are role in the end skin-related problem. We have great unaware of the facts. Part of the programme, problems even investigating cases of allergic contact regarding these initiatives is for trade unions and dermatitis, looking at the material safety data sheets others to get involved in that campaign, and to help that are often provided by companies because they the HSE with that campaign because they cannot are often incomplete and it takes a great deal of time achieve outcomes by themselves. Amicus and other and eVort to be able to identify what the sensitisers trade unions have undertaken to help the HSE. One are. Legislation is useful, obviously, and it does help, of the things we are doing is introducing this type of but there are changes that need to be made to make material and these initiatives into our education even the investigation of such cases easier for the programme, where we ask our safety representatives clinicians. to take the material that they have learned back into Professor Agius: I certainly agree with what Dr Orton the workplace, because they have direct access to and Professor Newman Taylor have said and I would safety committees, especially in large companies emphasise that the steps have to start at the very top and direct access to employers’ health and safety following the hierarchy in the Control of Substances professionals in there. This campaign can only be Hazardous to Health regulations, so every eVort eVective if run together with employers and trade must be made to substitute harmful agents for ones unions and other work/employee organisations. It is which are less harmful and to reduce exposure. All about awareness. It is okay sending a leaflet out to too often we find that convenience in using certain hairdressers so that they can have a look at it, but this agents is exposing workers to greater risk, so we find needs supporting. I did make some suggestions, we that people are using aerosol sprays to clean surfaces ran a campaign on prostate cancer several years ago because it is quicker to use an aerosol spray and just allergy: evidence 99
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton aim it in various directions than it is to use a gloved push needs to be made in relation to allergies to hand holding a hand wipe. It is those steps that have identify properly the sensitisers in these materials. to be implemented at the highest level insofar as what manufacturers produce and what employers expect Q276 Lord Soulsby of SwaVham Prior: Is it by way of work practices, and only after all those legitimate to refuse employment to someone who is things have been done is it then possible to try and known to be allergic to items in the workplace? achieve, a final level through personal protection and Mr Miguel: I would not say it as illegal, although the education of the workforce. In response to the earlier disability law has to be considered, because if you question about hairdressers, I do share some of the have a pre-employment check which asks those doubts that have already been expressed by witnesses questions then the employer is not going to give that as to the extent to which education alone will help as a reason. They will just refuse employment. things. The proof of the pudding will be in the eating. Sadly, hairdressers have got a very high incidence Q277 Earl of Selborne: Can I ask a question with especially of dermatitis, possibly to the order of one reference to REACH? This has been in the oYng for per hundred per year, and it should be possible to an awfully long time, it seems to me, and it never track and prove in due course whether or not these seems to quite come to fulfilment and it only deals interventions have helped and whether the legislation with chemicals and not with other substances to has helped. which there might be an allergic reaction. Do you Mr Miguel: The legislation, COSHH, as it is generally have much confidence therefore that REACH is known, is procedurally fine and it can transpose to going to help? allergies easily: identifying a sensitiser, calculating Mr Miguel: I think REACH will help as long as it is the risk to the person and controlling this using a combined with existing legislation and existing hierarchy, and the hierarchy is first to eliminate the guidance because that point has come out on several hazard in ways that have been described or using committees, that REACH was going to overshadow engineering controls and so on. The downfall with it COSHH, which includes biological hazards. That is that it is too generic and in cases that are complex, would be unacceptable because you can see from the such as this, identifying the hazard, identifying the example I gave you that there was a process, and sensitiser, is easier said than done. In the Powertrain information from suppliers did not identify the incident at Longbridge the sensitiser was not sensitisers which come from that process, it was not identified, and there is evidence that the causative the original chemical, so there are going to be faults agent could have been bacteria. There is also evidence with REACH but that has to be backed up further by that biocides used in the metal cleaning fluid also UK legislation. contain endotoxins which could be a sensitiser. These are all complex issues which a major company failed Q278 Viscount Simon: What training do health and to pick up, so the legislation was there, and the safety inspectors receive with regard to occupational procedures were there, but obviously you have to allergic diseases and is this adequate? Do you think identify the hazard in the first place. If there is no there are enough health and safety factory inspectors research, or if there is low level research or that for small businesses, such as the car spraying research is not published, then the employer is not operations that you have already mentioned? going to pick that up. In relation to data sheets, data Mr Miguel: I do a lot of work with the Health & sheets are very generic themselves, so in this instance, Safety Executive so I know the answer to this. When the data sheets said the health risk was irritation to they begin their training, they get an occupational the respiratory tract. It did not mention possible health tutorial, which includes allergies, this includes bacterial contamination of the metal fluid when it respiratory diseases, skin sensitisation, asthmagens was in use, so we were just looking at the metal fluid and COSHH, so they do get training in the itself, not the process, and no specific respiratory beginning. This is reinforced by experts that work disease was mentioned. It did say that local exhaust within the Health & Safety Executive, so inspectors ventilation could have been used if the mists were can call on colleagues. When they go to sites in the excessive, but did not describe “excessive”, so the first instance, if there is a specific thing, such as information available to employers from this occupational asthma, they usually have a specialist legislation, and data sheets, is inconsistent and it does colleague with them. If they have a specific not help employers. It helps the HSE to prosecute intervention which deals with risks to skin, for employers if they go wrong, but it does not on its own example, they take a colleague with them and they get help employers enough. More work needs to be done advice from that colleague, so they do have training in relation to COSHH. There is some new European from the beginning, which is reinforced by legislation coming up called REACH which asks the supervision and by experts. The HSE also have supplier to identify the hazards/risks and I think a doctors and nurses and occupational hygienists. I do 100 allergy: evidence
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton not have any measure of whether that training is the disease suYciently early there is the potential for suYcient but I know the training exists and is fairly it to resolve completely. Take someone who has comprehensive. occupational asthma due to, let us say, to being a Professor Newman Taylor: Could I just add to that? baker working with flour. The major problem they You asked about suYcient numbers. I suspect that have is that they are unable to return to work in an the numbers are not suYcient, nor could they ever be environment where they come into contact with flour suYcient. If we are thinking about asthma in or the enzymes that are added to flour in the baking hairdressers, to be able to have individuals who are process. What we need to put into place is a system going to be able to focus at that sort of level in such which provides support to enable them to retrain and small workforces I would think is asking a great deal, go into alternative employment. The problem for so therefore we need to look at other means many cases of occupational asthma, and there have additional to HSE or ways in which HSE can be been several studies that have looked at this, is that supported in terms of bringing awareness of the somewhere between a third and a half of cases of problems and education as to how to reduce their occupational asthma remain unemployed three to incidence over time. five years later. They have had to leave their work because of the risk of progression of the disease if Q279 Chairman: Professor Newman Taylor, could I they remain there and of it becoming chronic and are ask you how much you think occupational asthma is unable to find alternative employment. What I was compounded by smoking in the workplace or suggesting in that letter is that the Industrial Injuries smoking overall? Scheme could have a benefit which could be applied Professor Newman Taylor: There is evidence that for to that. There was a benefit called Reduced Earnings some, particularly chemical, causes of asthma the Allowance. Reduced Earnings Allowance was risk of developing occupational asthma has introduced originally in the late 1940s with the increased. You see that clearly with platinum salts Industrial Injuries Scheme which enabled people who and acid anhydrides but they are relatively small had pneumoconiosis to move into other jobs where contributors to the overall burden. With regard to the they were less exposed to coal dust and therefore less evidence we have in terms of the extent to which it at risk of progressing to Progressive Massive increases the probability of getting occupational Fibrosis, so it had a very important preventive role in asthma, probably it does not contribute very greatly. terms of coalworkers’ pneumoconiosis. It was an On the other hand, if you are a cigarette smoker and earnings replacement which enabled that to occur. you develop this disease then the consequences may That was withdrawn by the Government of the day in be worse because you are smoking as well as having 1990 and so that is no longer available. What I would asthma due to this. hope in the reform of the Industrial Injuries scheme is that there will be a benefit, which could be time Q280 Earl of Selborne: Professor Newman Taylor in limited, which would be focused on providing his written evidence refers to the need to provide a occupational rehabilitation and retraining for people means to support retraining for individuals with who have those conditions, of which asthma is a occupational asthma for the facilitation of new jobs notable example, where continuing exposure leads to and presumably there is a need for other progression of the disease and the appropriate route occupational allergic diseases and you refer to the to take is avoidance of the exposure. At the moment review of the Industrial Injuries Scheme. Could we people may not bring their disease to attention hear from you—and I am sure Mr Miguel will want because they are concerned they will lose their job to come in on this also—on what you would like to and will not get another one, so we are in the worst of see as the outcome of this review of the Industrial both worlds. Injuries Scheme and what new training schemes or Dr Orton: I would agree wholeheartedly with other measures might be appropriate? Professor Newman Taylor’s aspirations, but with Professor Newman Taylor: If I can focus in terms of regard to the skin there are a couple of complicating the review of the Industrial Injuries Scheme on how factors. The evidence at the moment suggests that if it impacts on this, one of the problems with the people with occupational skin disease change their Industrial Injuries Scheme at the present time is that employment it may not always result in a significant the way in which benefits are provided for prescribed improvement in the prognosis for those individuals. diseases and industrial accidents is uniform. It is There is also the condition of PPOD, or persistent essentially a benefit which is provided for so-called post-occupational dermatitis, which is when loss of faculty, that is to say impairment, and the level somebody develops dermatitis in an occupational of disability which is caused by that. If one thinks of setting and you then remove them from that someone who has occupational asthma, and occupational setting and the exposure, yet their dermatitis may be similar to this, if you can identify dermatitis persists. There is some evidence from allergy: evidence 101
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Australian large-scale studies that up to 10 per cent representations not being made to try to secure much of the workforce within their study group developed greater priority for training in this for medical this particular condition, so that also has to be taken students? into account when one is considering retraining or Professor Agius: Yes, representations are being made. taking people out of various employments when they For example, the Centre, and the Faculty of develop dermatitis. Occupational Medicine to which I belong has yet again, and has done so in the past, embarked on Q281 Lord Taverne: What training do general initiatives to bring this to the attention of medical practitioners receive about the treatment of educators. I think what tends to happen is that there occupational allergic diseases? It has several times are lots of other specialities and interests, with good been stressed, and now again by Professor Newman cause, vying for their own special features to appear Taylor, that what is so important is early diagnosis. in the curriculum but, given the fact that most people Do GPs receive suYcient training in the diagnosis? will present in the first instance to their GP and that Professor Newman Taylor: I would think it unlikely. such a huge burden on health could be prevented at Occupational health and occupational disease are that stage by early recognition and early steps, yes, I not usually a part of the undergraduate training do believe more should be done to train GPs. programme. It is not seen to be usually as important Dr Orton: I agree with my colleagues in the points a part of a general practitioner’s training as the other they have made today. Even in dermatology the conditions which they may see and so therefore their undergraduate curriculum usually consists of only knowledge of these conditions is probably not great. two weeks’ attachment, whereas 20 per cent of all GP Added to that, the number of cases that they will see consultations involve some form of dermatological individually is not going to be huge and so therefore problem. We have to tackle it from another angle their experience and the need to understand this is not because what we need to do is improve the pathway as great as it might be. My answer to your question is of the patient. Obviously, the GP has to be aware that that I think it probably is not enormous. We have run occupational allergic disease exists but it is getting a clinic for patients with occupational lung disease, that patient through to specialists as soon as possible the majority of whom have occupational asthma, and that we have to concentrate on. we see about 250 cases a year, and of the order of 5 to 10 per cent of those patients are referred to us Q283 Lord Rea: How often is the subject of by general practitioners. It is a relatively small occupational allergic disease—asthma or dermatitis— proportion of the cases that come to us. The majority included in postgraduate programmes organised by come to us from occupational physicians or from postgraduate deans for general practitioners, for other specialist physicians. trainee general practitioners, for registrars and Professor Agius: By training I am a specialist in principals in practice? There are these courses all the occupational medicine and I have never practised time going on. How often do they include an element in general practice. However, I am involved in of occupational health, including allergy? undergraduate medical education in a number of Professor Newman Taylor: My answer is that I suspect British medical schools, including my present one. it is in a minority. I do not have definite data but I am Sadly, I think it is fair to say that the level of training very familiar where my colleagues and I are asked to that the average British graduate gets in the talk, and we give many talks to postgraduate recognition of occupational allergic disease is meetings. It is a minority of those for general exceedingly limited to the extent that when we set up, practitioners; the majority is for other specialists. about 18 months ago, a scheme for recording reports Chairman: I think it is probably a question we need to of occupational allergic disease emanating from ask the GPs in relation to that. general practice, because they are, if I could use the analogy, at the base of the pyramid as compared to Q284 Baroness Platt of Writtle: To which specialists specialists, we felt we could not rely on the average do GPs refer patients suVering from occupational general practitioner. We had to select from the few and allergic diseases and how often do these thousand GPs who have what is called a “Diploma in referrals happen? Occupational Medicine”, and even then, in my Professor Newman Taylor: I would have thought that judgment, they rarely have had the sort of training they would refer them particularly to respiratory which the average graduate ought to be getting but chest physicians for occupational asthma and is not. dermatologists for skin conditions. Those are probably the two most commonly referred because Q282 Lord Taverne: Given the importance of this, those are the circumstances in which the cause and both in terms of the impact on individuals and the eVect relationship is clearest. Clearly, somebody who quality of their life and of the economy in general, are has occupational deafness may be being sent to an 102 allergy: evidence
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ENT surgeon, but there is nothing to distinguish that coming to retirement age and there does not seem to deafness symptomatically from deafness that occurs be the number of individuals coming through who in the population as a whole. I am unable to speak for have a particular sub-specialist interest in this area, other clinics but from my perspective, the majority of so there is going to be a problem in the future almost the occupational lung disease cases referred to me, certainly. come from occupational physicians, nearly two- thirds; a third from other specialists; and 5 to 10 per Q286 Chairman: Is there also a problem in terms of cent is from GPs. the number of consultant posts that are not being renewed now? Q285 Baroness Platt of Writtle: Then to take the two Dr Orton: Without getting too much into a political major causes, considering a number of people suVer statement here, dermatology is a speciality under from occupational dermatitis, are there currently threat also, being moved from hospitals into enough specialists in that area and will there be a a primary care setting and, indeed, much of potential shortage of specialists when the present dermatology now being undertaken by primary care cohort of occupational asthma specialists retire? physicians—and this of course here, relates to the Professor Newman Taylor: The situation with previous question—they will not have received any occupational asthma is that I think there is a need for specific training in occupational dermatology so we a relatively small number of sub-specialists who have are entering a downward spiral here which I can only this as a particular interest. The reason there needs to see as a future problem. be a small number—it is not something which all chest physicians can provide—is because there are Q287 Baroness Platt of Writtle: Whose particular factors which, in terms of understanding responsibility would it be to put this right, because the nature of work, the relationship of work to the for both allergies you are saying that there are asthma, the investigation of the cases, which can retirements and this is going to be a problem? Who include inhalation testing, and then the management should be taking it up? of the case subsequently which need interaction Professor Newman Taylor: I would suggest that the between employers and others involved in the future Department of Health needs to take responsibility management of these cases. It seems to me that it is with regard to this and I say that because for any important there should be a number of specialists in individual hospital moving into the era of foundation this field, not least because it is very important to trust status, where clearly financial viability is an identify a case because, as I said in terms of asthma, extremely important issue, we are talking about two you have the chance, if not of cure, at least of specialities where the revenue which will be received improvement. I would agree with my colleague that in terms of patient care is certainly not as great as, let not all cases of asthma resolve, but the majority will us say, somebody who is going to need to be in an improve when they avoid exposure. Equally intensive care unit. If there is going to be an area devastating is if you say to somebody, “Your asthma where people will wonder is this in fact an area where is caused by your work”, and it is not, “You need to we should continue to focus on, it must be one of the change your job”, and they do so and they do not areas that a chief executive must wonder for the need to have done it. That, I have to say, is something reasons that I have given. Occupational dermatitis which I see not infrequently because of a lack of and asthma will be services that will be at risk. knowledge of what is needed to make a confident In those circumstances, unless there is either diagnosis so you can give confident advice. There are Department of Health or, a specialist commissioning six or seven specialists within the UK who have this process where there are funds made available for it, as a particular interest and it is the case that many of which is the way it probably can best be done, I can us are now reaching retirement age. I think that there see this as something which no individual hospitals is a real need to ensure there will be successors, might see as their responsibility to continue. otherwise experts in the field will go. That is something which I would say at the moment is not Q288 Viscount Simon: Professor Newman Taylor, secure. you have mentioned the specialists to whom patients Dr Orton: I would agree with all of those points. With can be referred. Is there any particular reason why respect to dermatitis, it is very important to have sub- you have left out allergists? specialists with a particular interest in occupational Professor Newman Taylor: In the main, no, I have not disease because that is going to provide at the end of really, but the reason that I am focused on the day the best management for the individuals who respiratory physicians and dermatologists is that the come to see them. Equally, within dermatology, majority of these sorts of patients are referred to many of my colleagues who have an interest them. If you have allergists who have a particular specifically within occupational dermatology are also interest and have received training in occupational allergy: evidence 103
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton disease then, of course, within their area of interest respiratory protection. That certainly I would advise there is no reason why that should not be in circumstances where it provides the individual appropriate. The majority of allergists have focused with the time to look for and obtain other on hay fever, asthma and dermatitis, the broad employment. If you have got someone, for instance, spectrum of it rather than focusing on the who is a PhD student and is two years into it one occupational component. would work quite hard to enable them to complete their PhD which also gives them a year in which they can look for alternative employment, let us say Q289 Lord Broers: What course of action would working with tissue rather than live animals. It is not typically be recommended for a patient suVering hard and fast, but clearly the aim is to avoid from occupational asthma or allergic skin exposure. conditions, and at what stage is a patient advised to Mr Miguel: My Lord Chairman, on the employment give up work? issue, it is very diYcult because a lot of these people Dr Orton: First of all, within normal practice we go to their GPs and their GPs may advise them to would make a risk assessment for this individual and give up work, but that does not necessarily mean the we would perform the necessary investigations to employee is going to go back into work and give their arrive at a diagnosis, whether it is allergic, irritant job up, they may work on. We have done some work or both, and whether there are constitutional with certain employers regarding security of susceptibilities. As I mentioned briefly, giving up employment policy, whereby they re-deploy those work is not always the answer because, certainly with people in the same plants in diVerent rolls,—Rolls- regard to dermatitis, it does not always significantly Royce is a good example. Which leads to a further lead to an improved prognosis. There are cut and question, if they do have to give up work what sort of dried cases where it is purely an allergic contact training is available to them? There was a mention of dermatitis and the patient is meeting that particular the benefits system, to clarify a point, reduced allergen only in the workplace. There are some earnings benefit at the moment is being replaced by allergens which are found not only in the workplace working tax credit. However, the benefits system but also in the domestic environment and part of the itself does not help people to get back into work management for that particular patient is teaching because if you have a look at the benefits system, one the patient about these exposures. However, in the example, you need to be oV work for about 30 weeks clear-cut cases it is sometimes necessary for these before you can claim for your mortgage. If you go individuals to leave work, particularly if they are back into the workplace, you lose that benefit and volatile allergens and there is not going to be any way start from square one; I think they allow four weeks that they can avoid exposure in their current place of grace. Who in their right mind is going to go back work. Obviously it is very diYcult to give a generic into the workplace, or be encouraged to go back into answer to this and each case must be taken on its own the workplace when they are going to lose this type of merit and has distinctive features. benefit and they have to start from square one again? Professor Newman Taylor: Talking about asthma, in For example, they would have to wait for 30 weeks to part it relates to the nature of the agent and in part have a mortgage payment. The benefits system is not the severity of the asthma which is occurring. One has helping at all. The diagnosis and the fear of medical confidentiality breach’s are not helping. We would to look at it against the background that the evidence like to see a proper government-led training initiative that there is would suggest that the longer you for people with allergies which involves job centres, continue to be exposed to the cause of your asthma, where job centres are aware of industries where these the greater the chances are the asthma will become allergies occur, and to re-train those people at the irreversible, so there is a need in the individual case to same skill level as they had before, getting the same avoid exposure both to prevent acute reactions pay because what we are trying to do now, is to say and also the risk of progression. Agents such as to them “You are no good for this job now, or, you isocyanates, which are volatile chemicals, are can do this job where it is half the pay and we will try Y Y extremely di cult to avoid su ciently if you become and top that up using tax benefits”. In fact, it does not sensitised to them and to prevent the progression of work so I think we need to look at the benefit system asthma. In general, for people exposed to chemicals quite carefully, look at the way the diagnosis is such as isocyanates, one would recommend that they happening, and how the information is getting back should avoid exposure in some way, and to the extent to the employer, because the employer, or the job that it is possible one looks to try and see if relocation centre are not getting adequate information or using is possible within the factory or workforce in which it correctly. the person is involved. There are other allergens, particularly with particulate agents, such as flour or Q290 Lord Broers: How much do you get involved laboratory animals, where it may be possible to with small companies? What if it is a small paint shop enable people to continue at work wearing suYcient where they are flagrantly ignoring safe practice? Do 104 allergy: evidence
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton you get much involved with that, if these might be industry and looking for large outbreaks of organisations of only half a dozen people? sensitisers causing problems are very much lower Mr Miguel: Unfortunately, trade unions are usually than they used to be. It is usually the smaller industry involved with big organisations, but I do get involved and smaller workplaces where the majority of with small organisations of about 50 employees patients now seem to be coming from. where they have this sort of problem. I do not want to name the companies here, but we do get involved, I do go on to site and give them advice because Q294 Lord Rea: The Health and Safety Executive they have limited knowledge on re-deployment, on regularly convenes a group of occupational allergies, on information about what is an allergy, respiratory disease specialists with the aim of and what is a sensitiser but very rarely, because trade developing a document setting out standards of care unions are more involved in major companies than for the diagnosis and management of occupational smaller ones, but that is changing. asthma to circulate throughout the medical community. What recommendations do you think should be included in this report? Am I right in Q291 Chairman: Given the shortage of specialists thinking that this group is the same or related to that there is and the importance from the Union’s SWORD? It seems to be very much covering the point of view of accurate diagnosis, which you same area. highlighted earlier on, has the Union thought Professor Newman Taylor: I think it is a diVerent about developing its own service and employing an group from SWORD. SWORD is the reporting allergy specialist itself, or part-employing an allergy scheme, which Professor Agius is now responsible specialist itself? for; GORDS is an informal group of respiratory Mr Miguel: No, that is not something we consider. We do work with employers and their occupational physicians who have an interest in occupational health departments, but we do not think that it is the disease which has been convened by the Health and trade union’s role to supply specialists, it is the Safety Executive and meets two or three times a year. employer’s role to do that.3 One of the proposals it is currently looking at is this question of setting out standards of care for the investigation and management of patients with Q292 Lord May of Oxford: This is a question that occupational asthma. The answer is that it must be a probably reflects my ignorance. We have heard that worthwhile endeavour because it is going to improve, one of the major sources of allergies was among or its promulgation should improve, the quality of hairdressers and I was under the misapprehension diagnosis and management of this condition. that a great proportion of hairdresser outfits were Whether or not it will do anything to increase the small businesses. Am I wrong, because if I am right number of cases that we are aware of is really another then that means that is a really very significant issue because that is all about individuals either at problem, of this issue not being addressed because general practice level or specialist level recognising you are typically dealing with larger outfits? that a case may be attributable to their occupation, Mr Miguel: I will answer that very quickly. They are small businesses yes and they have got very little bringing it to attention and investigating it occupational health advice, although the HSE is appropriately. I think it has the potential to improve trying to bring the schemes forward, so, therefore, the standards of care; the extent to which it will increase campaigns which we talked about earlier are very awareness and, therefore, increase the number of relevant to reaching those small businesses and some cases I am less sure about. Just as a footnote to that, of the media tactics that I mentioned, but, you are last year I chaired for the British Occupational quite right, they are small businesses in need of help. Health Research Foundation—a committee which published guidelines on the prevention, diagnosis and management of occupational asthma. These Q293 Lord May of Oxford: They sum up to a large have now been incorporated into the British Thoracic number. Society guidelines for the management of asthma and Mr Miguel: Yes. have been circulated to all respiratory physicians. So Dr Orton: I would like to comment on that. Amongst I would hope that at least at that specialist level that hairdressers, in occupational skin disease, allergy is a information is getting there already. For this to make part but irritancy is probably a greater part. In my an impact, it is going to have to get beyond the own practice and when I am talking to other specialists who are currently seeing the cases. dermatologists, the days of going into a large 3 AMICUS has various partnerships with industry bodies, for example Electrical Contractors Association (ECA) and Q295 Lord Rea: I hope so. What about a similar AMICUS form the Electrical Joint Industry Board (JIB). This and our other partnerships, have health care provisions as part document being produced for occupational allergic of its benefits to employees. skin disorders? allergy: evidence 105
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Dr Orton: I am not aware of any current work that is asthma. If we look at occupational physicians who being co-ordinated with the HSE for that. report a large number of cases, probably an estimate of about 10,000 cases of all work related disease per Q296 Lord Rea: Do you think it would be desirable? year, but then in them a much higher proportion of Dr Orton: I think it would be desirable, absolutely. the respiratory cases would be asthma because that tends to temporally have quite a close relationship to work exposure. Whereas chest physicians tend to Q297 Lord May of Oxford: This is a question proportionally report a majority of cases of non- primarily I think for Professor Agius. The University allergic diseases related to asbestos. That is the of Manchester, as I understand it, runs several answer in a nutshell. schemes that collect data involving occupational and allergenic diseases. What proportion of the cases reported in these schemes has an allergenic basis and Q298 Lord May of Oxford: And the trend or the how has the number changed in recent years? time? Professor Agius: My Lord Chairman, yes, his Professor Agius: As I mentioned earlier, trend is Y Lordship is correct, we do collect data from a number something which is di cult to establish because there of schemes. Historically, the schemes in their origin is a number of artefacts which can explain apparent were based around specialists, for example the trend. We are doing our best to take account of those specialists of interest today are mainly respiratory artefacts. By “the artefacts” I mean changing physicians, dermatologists and occupational denominators of the number of doctors who report, physicians and, as I intimated earlier, they reflect very who leave the schemes, and who join them and much the tip of the iceberg. The shape of the tip of the phenomena like fatigue which doctors tend to iceberg gives us very little indication of what the experience when they are expected to fill in lots of iceberg’s shape is like below the waterline, so we have forms and paperwork. Having taken account of been arguing for a few years that we should collect those, we do get a linear trend assumption of a data closer to the base by getting information from reduction of about seven per cent per annum in GPs and, indeed, we did launch such a scheme 18 incidence, but that is subject to lots of caveats and we months ago. In very round figures because the results are investigating that further. Once we have data in are preliminary, based on the information in the due course from the GPs, then we might be able to be reports GPs give us, out of the totality of work- a little bit more certain, or perhaps uncertain, as to related disease that they see, about one in 10 relates how accurate that estimate of trend is. to skin and the vast majority of that is occupational contact dermatitis. The GPs are not very well Q299 Lord May of Oxford: Among those caveats, as qualified to determine what proportion of that is I understand it, first of all, some of the less severe allergic and what proportion of it is non-allergic ie cases do not present themselves through diagnosis. irritant. However, based on the information that the The scheme of reporting is voluntary and so there specialists give us, and that has already been alluded have been suggestions that maybe there is under- to by my colleague, Dr Orton, we would expect a bit reporting, or perhaps, alternatively, biased reporting. less than half of those to be allergic at least initially. I wonder, beyond what you have said, whether you Then as far as respiratory disease, about one in 20 of think there is validity in those criticisms and, if so, the cases of occupational disease that GPs report to what you are doing to try to address them? us generally consist of respiratory disease and the Professor Agius: There is validity in some of those vast majority of those would be either asthma or criticisms, my Lord Chairman, indeed I have asthma-like syndromes, perhaps not yet fulfilling the conceded some of them. Having said that, the full definition and not yet proven by specialists. The schemes are one or two orders of magnitude better majority of those would have allergic features than the statutory mechanism. The statutory although, as my colleague, Professor Newman mechanism, namely RIDDOR, the Reporting of Taylor, said, not all of them might fulfil all the Injuries, Diseases and Dangerous Occurrence immune criteria. If we now look at the totality of the Regulations, is, by the HSE’s own concession, at data we get, but, as I said earlier, this is very much least by personal communication, “positively influenced by what the specialists tell us, we get an misleading”—I call it negatively misleading—in as estimated 20,000 cases of occupational disease every much as they now no longer publish the results from year, of which about 2,500 are reported cases from that. On questioning, they say they have through dermatologists and about 2,500 from occupational RIDDOR about 40 cases of asthma per annum and physicians. Of the 2,500 from dermatologists it is 120 cases of dermatitis per annum on average over estimated about three-quarters of those are the last few years. That in itself is one-tenth, or less occupational dermatitis and 15 per cent from the than one-tenth, of the specialist cases that we get, and 2,500 or so estimated cases from chest physicians are that is in itself per annum probably one-tenth of the 106 allergy: evidence
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figure if one takes a look under the figures further, them at specific times of the year at which at random between what our GPs see and what is then onward we ask them to report and we encourage them to referred. As your Lordship has mentioned, of course, report rare things at other times as well. In a number of cases go under-reported. So far as the conjunction with the research which I have already criticisms, they all tend to suggest that if anything the described, we also have got research trying to relate data is an under-estimate, so when in the past we have rare causes of asthma, and indeed of dermatitis, to looked at the possibility of over-reporting, duplicate chemical structures and so on to try and develop a reporting, between diVerent specialists we have strategy to be able to identify early novel causes of found this amounts to maybe one or two percentage occupational asthma and occupational dermatitis. points only amongst reports. Having said that, for ethical reasons, we are not allowed access to the names, dates of birth or even initials of the patients Q302 Lord May of Oxford: Finally, here is a chance concerned so we cannot be dogmatic about the extent for you to lay down a marker, but I am curious how of over-reporting. However, when we have done long the project you have in hand is going to specialist studies on this, the problem is not one of continue, where the future funding is going to come over-estimates, the problem seems to be one of from and, more generally, how you feel about the under-estimates because when we compare our data funding for this kind of vital factual underpinning of with specific focused surveys in specific industries in what we are talking about? good epidemiological literature, then those would Professor Agius: The HSE funding for data collection suggest that the incidence is, if anything, higher than from the specialist schemes ended when data the incidence that is reported to us. collection finished at the end of last month, we are now carrying the schemes partly through reserves of funds and partly through charitable support. The Q300 Lord May of Oxford: I had occasion recently HSE provided us with a commitment in principle 10 V in a di erent context to meet with the British months ago to fund specialist schemes for a further Paediatric Surveillance Unit and, first of all, many of five years, but they tell us that they are under severe the cases of allergy, and particularly in our visit to St financial constraints and so far that commitment has Thomas’, are among younger people. The British not been made good into a contract, which we Paediatric Surveillance Unit has the responsibility, as seriously need because we have good staV leaving. In I understand it, for collecting data on things that are so far as the GP schemes, these are funded for data not very prevalent. I did really wonder a bit about the collection into November of next year. Funding in sensibleness of the conjunction of that constraint occupational allergic disease, as in all occupational with the need for really good data on the incidence disease, I think is very much a Cinderella issue. It among very young children. Do you have a comment does not engage the same sort of high profile as on that? funding for other causes of ill-health. A lot of the Professor Agius: My Lord Chairman, our remit funding, these days, what little there is, comes from extends to people in employment who either present charities like the Colt Foundation and so on. themselves to their GPs, specialists or occupational Funding from government is tiny and we are told by physicians. the HSE that it is now severely constrained compared with what it was before. Q301 Lord May of Oxford: Yes, but setting that aside, do you feel that the question of getting good statistics on really young people is handled well, Q303 Earl of Selborne: I will follow up that point because after all you are one of the experts on these because it is clear that RIDDOR was never providing databases? the information which was accurate it was under- Professor Agius: We have put forward proposals for reporting of ill-health, according to what Professor research that would involve studying cohorts of Agius has told us, and Health and Safety required young people and some work has been done on that RIDDOR, to provide itself with the information on but perhaps not enough. There are, for example, ill-health caused through allergic diseases, yet you asthma cohorts already in existence, some of which have not apparently expected the Health and Safety my colleague, Professor Newman Taylor, is involved Executive to replace RIDDOR by funding the with. If there were to be funding to permit those to be Manchester University schemes. Would you like to followed up prospectively they might give us some comment on that? answer to your question. As to rare conditions, Professor Agius: We are hopeful and optimistic that specifically we encourage our doctors to report things we will be able to persuade the HSE to make tangible which are rare even if they come outside the sampling its in-principle commitment to extend the funding of frame. If I may explain, my Lord Chairman, so as not these schemes for a further five years. So far that has to tire our doctors out too much we sometimes target not happened but we are hopeful that it will. We allergy: evidence 107
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton appreciate that they are under severe financial Dr Orton: From the dermatitis perspective, I would constraints. Having said that, we do feel that, as an have concerns and diYculties in making these criteria area which contributes a great deal to the health because the assessment of dermatitis, as I have burden of the nation, not just occupational allergic alluded to before, is extremely complex with disease but occupational diseases in general, it is constitutional genetic factors, irritancy as well as grossly underfunded and tends to fall between allergy. Although we have a standardised test to various stools. identify if somebody is allergic to a chemical substance, those substances are not only found at work, but they are also found in people’s domestic Q304 Lord Soulsby of SwaVham Prior: The written environments and it is a very confused area and needs evidence that we received from the Government is teasing out. Often, certainly in medico-legal cases, it that there is no simple test for objectively confirming is down to a degree of subjective interpretation and cases of work-related allergic disease. Do you think one’s own experience. that the introduction of standard criteria for diagnosis for accepting an occupational origin would Q305 Lord Soulsby of SwaVham Prior: Basically you be useful in measuring the incidence of these diseases are both saying that we are not at the present stage of and what should be the criteria? utilising the standard tests for evaluation. Professor Newman Taylor: I will restrict my comments Professor Newman Taylor: I think there is a number of to asthma. In fact, there are methods which are tests which are utilised in the diagnosis of asthma and available which can be applied that provide that one can use standardised criteria for deciding confidence in the diagnosis of occupational asthma. whether or not they are likely to be positive or One can ask those in whom it is suspected to make negative, but there is clearly an important element of regular measurements of their peak flow, which is the individual judgment in relation to the results of those maximum flow of air which can be achieved at the investigations which leads you to determining mouth, at regular intervals over several days when whether or not it is likely to be due to the particular they are at work and away from work and compare occupational agent. the two. In many of the cases you can see a real Dr Orton: For skin, I would say that those tests are diVerence between the two as the asthma occurs, less conclusive. becomes increasingly severe at work and improves Mr Miguel: All the tests are non-conclusive and I away from work. It can be that you need a period of think it is very important to remember that any more than a two-day weekend to see suYcient poorly-validated criteria should not exclude anyone improvement, but it is certainly a useful diagnostic from employment and a past history of occupational tool. In those cases where there is evidence for an asthma, asthma or dermatitis should not exclude immunological response, then one can identify that people. I think it is a question of running an array of in terms of skin tests or specific Ig antibody in the tests. The immunological tests are 50-50, as I blood. In the final analysis, if it is really important to understand. This has to be backed up probably by a know what is the cause of asthma in an individual questionnaire which is a good way of finding out and case, it is possible to do inhalation tests, but health practitioners need to ask the right questions. inhalation tests are potentially hazardous and, When they see these people, they need to be aware of therefore, need to be undertaken in careful sensitisers in the workplace, the type of work that conditions in specialist centres, which is the situation person is doing and what materials they are using. now. The answer is that while there is no single simple The list of sensitisers used by the DSS is very limited test which says yes or no, there is a number of and there is a further extensive list of sensitisers and investigations which can lead one to being confident health practitioners need to be aware of those. as to whether it is present or not. I think that if one were to introduce standardised criteria in relation to Q306 Baroness Platt of Writtle: Is the prevalence of each of those, that could only be helpful. With latex allergy now under control or are there any other comparable diagnostic criteria it allows comparisons outstanding issues in this field that need to be of disease rates at diVerent times and diVerent places. addressed? Is there a danger for people who work in Whether that will enable one to better know what the supermarkets and shops that latex-containing incidence of the disease is I think is a diVerent packaging may produce or exacerbate contact question, because that is a matter of recognition and dermatitis? attribution of the asthma to a specific agent and then Dr Orton: In my own experience and from looking at of reporting that, which is something we have been the evidence, certainly amongst healthcare workers discussing. I can see potential benefits; I would you can see that the level of problems related to question whether it will improve knowledge of the immediate allergic responses to latex have now incidence of the disease though. plateaued out. My other colleagues might be in a 108 allergy: evidence
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton better position with regard to the reporting cause of a reaction to a glove. Also one has to identify mechanisms to confirm that. With regard to whether if there is an allergic component, if it is the immediate there are any outstanding issues, I would like to bring allergic response, for example to the latex proteins, or something to the fore. Often either for healthcare a delayed allergic response to the rubber chemicals workers or patients who are sensitised to latex, that they add to the latex, which are usually the ones hospitals and dental practices constitute very that give rise to the dermatitis developing, or a important sources of exposure and a danger for those combination of both. That involves investigating individuals. Currently the procurement of latex-free people further. equipment for hospitals and dental practices is undertaken on an individual basis amongst individual trusts and this is both time-consuming and Q309 Lord Taverne: You have told us something adiYcult process to obtain the necessary information about the funding, or the lack of funding, for the from manufacturers. I think it would be extremely collection of data. What about the funding for helpful to have some form of centralisation for this so research in general? Who currently funds the that individual trusts are not duplicating the majority of research into occupational allergic work involved and that it becomes an overall diseases in the United Kingdom and—I am sure the easier process. With regard to the question of answer will be “There is not enough of it”—is there supermarkets, the wearing of latex gloves and any particular section which is particularly under- dangers to the public, I think certainly people are funded? trying to move away from wearing latex gloves Professor Agius: My Lord Chairman, within altogether in supermarkets and the healthcare setting occupational disease I would not say there is a section to try and prevent problems. In terms of the dangers which is particularly under-funded because there is for consumers from shop workers wearing latex serious under-funding across the board. At the gloves, there is very little danger of people developing moment, the situation is worse than it has been for sensitisation to the rubber chemicals that are added some time because at least in the past there was a to the gloves, which are often responsible for the mechanism whereby one could apply for money from delayed allergic response producing dermatitis. the Health and Safety Executive whereas now that There have been case reports of residual proteins does not exist at all. There are some charities, like the within gloves that are thought to have become Colt Foundation and the British Occupational transferred onto foods causing the immediate type of Health Research Foundation, which will support allergic response in consumers and even from seals research in this area, but otherwise if one has a around foods. However, I think that those are a project which is of some interest perhaps to the minority of cases and it would involve individuals Medical Research Council or to the Department of who are extremely sensitive to the latex proteins. Health specifically we try and approach them, but by and large that is not seen as their remit, so the situation is dire across the board. I wonder whether, Q307 Baroness Platt of Writtle: What about my Lord Chairman, my colleague, Professor packaging? Newman Taylor, might add to that. Dr Orton: These recent case reports in the literature. Professor Newman Taylor: I think the situation is as Well, I think that one has to be aware of it and always has been described. The majority of the funding that think about that in one’s assessment of a patient, but goes into research on occupational allergic I am not aware that it is a major problem and it respiratory disease now comes from charitable V probably would a ect a minority of individuals. sources, of which the Colt Foundation is a major provider of funds for research into occupational ill- Q308 Lord Colwyn: I wonder if I can make an health, but also specialist charities, such as the British observation on that. Having worked as a dentist for Lung Foundation and Asthma UK, when there are about 40 years, I suppose I wore gloves for the last 10 areas within their interest, will also support it. I think or 15 years of my practising life and had terrible the issue in relation to the Health and Safety problems when I first had to wear these gloves. I Executive is a particular concern because for several thought I had latex allergy, but in fact it turned out years now the Health and Safety Executive has to be the fact that I was wearing rubber on my hands predominantly funded contract research for external for eight or nine hours a day and the hands sweat. I individuals to apply for. What we now understand is think it was something to do with that rather than that the Health and Safety Executive, because of the dermatitis, and I do not know how you tell the concerns which have been previously shared, is only diVerence. able to fund research within occupational disease Dr Orton: Glove reactions are extremely common within the Health and Safety Executive and Health and just the occlusive eVects of wearing the gloves, and Safety Laboratory. That is a situation which may whatever the material, are probably the commonest change, but it is a situation which appears to be the allergy: evidence 109
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton case at the present time. This has a number of being exposed. The really important determinant of problems: not only is it diYcult to undertake research illness with occupational asthma is the level of within the field, but it also provides problems in terms exposure, and the focus needs to be really on the of retaining people in the field and attracting people environment to reduce the level of exposure in order to come into the field, because if there is not research to reduce the number of those who become sensitised. funding for it then this is not an area of growth, and We looked at some data which we had some years therefore of interest, for people who would follow in ago in terms of laboratory animal allergy, and the future. Unless something is done to change the asthma caused by laboratory animals occurs about situation we risk finding ourselves in a few years five times more frequently in atopics than in non- without experts in this field because experts need to atopics, but it will occur in only a minority of atopics be doing research and research needs to be funded. and so if you are atopic the chances of you getting asthma are much less than of not getting asthma. What it meant in terms of a pre-employment screen, Q310 Lord Taverne: Are we in a much worse if one was going to use it for that purpose, was that position in this country than, say, developed you would need to exclude seven people to prevent countries in the rest of Europe or North America? Y Professor Newman Taylor: I think we are in a worse one case and that, clearly, is not su ciently position than Scandinavia, particularly, where they discriminating to be used for that purpose. Much have invested quite heavily in occupational disease more important really, it seems to me, is that the and have institutes. We are probably in a worse focus needs to be on improving the environment in position than is the situation in Canada. The United which the individual is working in order to prevent States is more diYcult to say, but probably there is the case developing in the first place. still a higher proportion of funding that is going to this area in the United States than here, but Q312 Baroness Perry of Southwark: Do you think in relation to Scandinavia and Canada we are there is a long-term hope of eliminating it entirely? certainly worse. Professor Newman Taylor: I think that it will be Dr Orton: Within skin, I would reiterate the same, diYcult in some circumstances. Laboratory animals that certainly in other parts of Europe, particularly in is quite a good example, people have to handle Scandinavia and even in Australia they have specific animals, you pick an animal up, it is likely to urinate institutions looking into occupational skin disease. on you, if it urinates it will scratch you, all of these We are very much behind. things could happen, the dust gets into the air. You could do a lot to reduce the level of exposure and, Q311 Baroness Perry of Southwark: I am disturbed therefore, reduce the incidence. To eliminate it I think by your answer to the previous question and I would be very diYcult. wonder what research is currently going on to Mr Miguel: My Lord Chairman, that is interesting identify those people who are at risk of developing what my colleague is saying especially about HLA. I occupational asthma? think it is quite worrying if we are going to go down Professor Newman Taylor: There has been quite a lot the lines of genetic testing in terms of excluding of work which has been done on that over the last 20 people from employment and, as was rightly said, it years and there has been work which has looked at is not conclusive. For example HLA B27, there is a the risk to people who are several atopic, that is to say predominance of HLA B27 in people with back they have skin reactions to pollen, mites and moults problems, but only two per cent of that group has and things, and also looking at some genetic markers, been identified as having back problems, so it is not such as HLA, to see whether or not these people are conclusive and it is possible then to screen out 98 per at greater risk of developing occupational asthma. cent. What we are worried about, as a trade union We have some evidence that is the case, that atopics movement, is that we are going to go down the lines working with laboratory animals, in bakeries or with of genetic testing and atopy which precludes people enzymes are at greater risk. Similarly with HLA, in from employment when it should not. The facts that relation to some low molecular weight chemicals, Professor Newman Taylor is talking about are very platinum salts anhydrides as well as with laboratory worrying if we are going to use that information for animals, there is evidence that there is also an pre-employment screening, which I think there is a increased risk. The problem is that these factors only danger that could happen. contribute a minority to the risk of the disease and the Professor Newman Taylor: To reassure Mr Miguel, concern that has been expressed already, which I that was happening 20 years ago and the research share, is that we are not in a position where those which we have undertaken demonstrating the markers can be used to identify those people who will importance of exposure has led most employers to develop a disease and, therefore, prevent them from abandon that as a means of pre-employment testing. 110 allergy: evidence
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Q313 Chairman: I suppose the other side is that you Q315 Chairman: It is the key aim. Do members of could be looking at people whose career advice at the Committee have other questions that they wish to school level might be better targeted in the random or ask or other points that you wanted to make? absent career advice that some youngsters get where Mr Miguel: My Lord Chairman, this is not my field they tend to fall into certain patterns of occupation, so I do not know much about it. I was reading some so there may be some benefit in the longer term of articles about desensitisation techniques. One of being able to steer youngsters to develop in diVerent them—and I am sure my colleagues will put me right pathways. or wrong—was to inject people suVering from hay Professor Newman Taylor: I think, as yet, we still fever and asthma with bacteria which used to be probably do not have suYcient information to be found in kitchen sinks which no longer exists, to able to give good advice on that basis. I agree with desensitise them for about a year. I do not know if you, maybe someone who has asthma who is going to any work is being done on that, but that sounds work in an environment where they are coming into promising and if we are able to get a technique where contact with isocyanates, but on the basis of atopy, we could desensitise people then that would be HLA testing or whatever, it is very important not to relevant research. discriminate. Professor Newman Taylor: The situation at the present Mr Miguel: To make a point on the issue just raised, time is that if we were looking at desensitisation due to the small genetic pool that we have, you will with occupational allergens, potentially the most find if you started carrying out that testing on promising might be the laboratory animal urine children no-one would be in employment anywhere. proteins. Professor Kay and his colleagues have done a great deal of work to make this safe because in the past it was not done suYciently safely. If I was going to promote a single area where one is looking at that Q314 Chairman: You have painted a gloomy picture as a means of switching oV the disease, so to speak, of the future really because we are not having the next it would be laboratory animal allergy where we know generation of researchers coming up through the enough about the proteins that cause it to be able to ranks and emerging, but if one tries to take a more make some progress. I wonder if I could make one optimistic view I wonder what you feel the most other point and that is that you talked about promising areas of research into industrial allergic research. It seems to me that what has been achieved skin disorders are in particular and who is co- in the last decade or so is that we have learned what ordinating and leading on this research? the major causes of occupational allergic disease and Dr Orton: There are two areas there that need occupational asthma in our community are. We have mention here. The first is work into persistent post- come to understand that it is more the level of occupational dermatitis, which seems to aVect maybe exposure than personal susceptibility and where 10 per cent of the workforce, and that is being there needs to be a focus for research it is translating co-ordinated at the Institute of Occupational that knowledge of exposure response relationships Dermatology Research and Education in into eVective means of preventing the disease or Melbourne, Australia by Dr Rosemary Nixon and reducing the incidence of the disease. As I have said, closer to us, in Germany, there is Professor Thomas with latex and enzymes that has been achieved. We Diepgen in Hamburg who is looking at the eVect of need to be looking at the means to be able to reduce intervention in patients with hand eczema, because disease incidence in other situations like with bakery primarily occupational skin disease does involve the workers and flour, supermarkets and isocyanate hands. There has been some evidence produced to workers in garages, if we are going to make a further date about these targeted education programmes, impact on this disease. getting individuals who are in wet work occupations Lord May of Oxford: It is a good question and it may to understand the function of the skin, what signs reassure you that the Committee has been excellently they should look out for if the skin is being damaged organised. We had a visit to St Thomas’ where some by exposure to irritants, or indeed allergens, and of this research is going on, and my personal what measures they need to take to treat it. It is impression, for what it is worth, is that there are still changing the individual’s behaviour with regard to more questions than answers. There is a lot of treating the skin at an early stage which is having progress occurring but we are a very long way from beneficial eVects. Certainly, in hairdressers and having a silver bullet that is universal. There is healthcare workers there is published data which progress more on some kinds of things than others. supports this. Obviously more work is being done in this field, but going back to Professor Newman Taylor’s point—reducing exposure is the key aim Q316 Chairman: Professor Agius, did you have here. another point? allergy: evidence 111
10 January 2007 Professor Anthony Newman Taylor, Mr Rob Miguel, Professor Raymond Agius and Dr David Orton
Professor Agius: My Lord Chairman, I would have to exposure. Historically, this country has made thought that the role of de-sensitisation would be significant strides in those areas in the past and has exceedingly limited to some exceptional areas, led. At the moment things are slipping away through although I defer to Professor Kay and Professor our fingers. Newman Taylor in this respect. I think the emphasis, as Professor Newman Taylor has said, has to be in Q317 Chairman: Dr Orton, do you have any most respects to apply what is already known and to additional points you wish to make? undertake the lines of research that determine the Dr Orton: I think they have really been made. incidence of occupational asthma, occupational Chairman: Then could I thank you all for coming and rhinitis and occupational dermatitis and to relate that the work that you put into giving us evidence today.
Supplementary memorandum by Professor Raymond Agius—in response to supplementary memorandum by Mr Ivan Lewis MP, Parliamentary Under Secretary of State for Care Services, Department of Health (p 320) Yes indeed we did meet the HSE on 4 April and earlier today I e-mailed the University’s response to the HSE. Since the unresolved funding situation is such that we are having to consider seeking “commercial sponsorship” we have had to consult our stakeholders and the last meeting we had with them was on Thursday 17 May. In essence our stakeholders would rather we did not seek commercial sponsorship since we might lose some participation and perhaps even some standing, but on the other hand commercially sponsored schemes are better than no schemes at all. The University has bent over backwards and has agreed to forego the “full Economic Costing” (fEC) basis of charging the HSE. EVectively through our own resources and some charitable support we were able to oVer to do the work to the HSE at around half the true “fEC” cost. However on 4 April HSE could only oVer us about one half of this already grossly reduced latter amount (ie just over one quarter of the fEC cost). In today’s response to the HSE we suggested another means whereby, with their agreement, we could save money on extant work that we are doing for them and thus reduce our costs for the extension of the THOR schemes even further. Yet there is still a substantial gap, and we await the HSE’s further response. Actually in relative terms these sums aren’t vast—they represent about 1–2 per cent of the money that we understand that the HSE pays every year to the Health and Safety Laboratory (which had unsuccessfully tendered competitively against us for the work in the first place). Yes indeed we have, together with other European partners, bid for EU FP7 money. However the outcome of this bid would not be known until around the end of the year. If successful it would provide considerable added value to what we do now, such that we would have data across the EU that is comparable in its quality— and compared in terms of outcome. However EU funding would not significantly reduce the “core” UK costs for the collection of the fundamental data on occupational illness and its trends that are so important for determining and monitoring UK national policy to prevent this ill health. In short: EU funding would amplify the basic work we do now but would not significantly “subsidise it”. 112 allergy: evidence
WEDNESDAY 17 JANUARY 2007
Present Broers, L Rea, L Colwyn, L Selborne, E Finlay of Llandaff, B Simon, V (Chairman) Soulsby of Swaffham Prior, L May of Oxford, L Taverne, L Perry of Southwark, B
Memorandum by the Royal College of General Practitioners 1. The College welcomes the opportunity to make submissions to the House of Lords Science and Technology Select Committee’s Call for Evidence on Allergy. 2. The Royal College of General Practitioners is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the “voice” of GPs on issues concerned with education, training, research, and clinical standards. Founded in 1952, the RCGP has over 24,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. Please find below a submission to the Committee’s Call for Evidence questions as outlined below the four topic headings:
Defining the Problem
What is allergy? What is the difference between allergy and intolerance? 3. The term allergy has evolved in medical usage over the last century so whereas once it referred to any type of immunological response, it typically now has a much more specific meaning referring to an immunological response to an antigen mediated by specific IgE. These reactions are also sometimes known as Type 1 or immediate hypersensitivity reactions. 4. At the same time as its meaning becoming more restrictive in medical usage, the word allergy has also penetrated lay social discourse, where it is also rapidly evolving, but in a way that sees it being used in an ever more broad sense. 5. Intolerance reactions are common and can result in significant morbidity. Although the underlying pathophysiological mechanisms are often not clearly understood, it is clear that these reactions are not specific IgE mediated. Clinically, these are far more variable in onset, less predictable and typically more transitory than allergic reactions; they are not life-threatening.
What is and what is not known about the origins and progression of allergic disease? 6. Allergic disorders can aVect people of any age, both genders and all ethnic groups. There are however considerable variations in prevalence of these disorders internationally. Allergic conditions often manifest first very early on in life, often beginning with eczema/dermatitis and food allergy in the first year of life, progressing onto the development of allergic rhinitis and asthma in early childhood, and other more systemic allergic disorders such as urticaria and angioedema typically manifesting more commonly in middle-age. Anaphylaxis is the most serious manifestation of allergy and occurs in children and adults.
Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such high prevalence of allergy? 7. The reasons underpinning these dramatic recent increases are complex and as yet poorly understood. Whilst some of the observed increases are likely to be due to a combination of better recognition, changes in disease labelling patterns and a lowering in the threshold for diagnosis, there has almost certainly also been a genuine increase in the incidence and prevalence of allergic conditions over the latter half of the last century allergy: evidence 113
17 January 2007 in the UK and elsewhere. The UK ranks highest in the world for asthma symptoms, with a prevalence 20-fold higher than that in Indonesia, it is also near the top of the world ranking for rhinitis and eczema.4,5 8. The narrow time window in which these increases have occurred makes it implausible that these changes are due to genetic factors—rather, they are due to environmental and gene-environmental interaction factors, which are aVecting large sections of the population, particularly in very early life (foetal development and/or infancy). Numerous risk factors have been suggested as being responsible for these increases, but as yet the reason(s) underpinning these increases remain elusive. Given the number of identified risk factors, it is likely that these increases represent complex interactions between a variety of environmental factors and genetic predisposition. 9. The epidemiological picture has become even more complex in recent years with indications that there may be diverging trends in the local and systemic allergic disease trends: the prevalence of the more local allergic disorders such as eczema, hay fever and asthma appears to have stabilised in the UK and may even be declining, although there are no signs of similar declines in relation to the more systemic allergic conditions such as food allergy, urticaria, angioedema and anaphylaxis.
What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 10. We currently have no data on Accident & Emergency consultation rates, hospital out-patient consultation rates and hospital in-patient prescribing, which makes it diYcult to assess overall disease burden from the point of view of the NHS. We also have no real idea of loss of time from work or school or understanding of the impact on day-to-day life, educational impact, career prospects and social activities of those suVering from most allergic disorders which renders it diYcult to assess the disease burden posed to individuals who suVer from many of these allergic problems. Strategies to filling these gaps include: — A more comprehensive range of disease codes and aetiological trigger factors for use in primary and secondary care (for example, there is currently no codes for peanut or kiwi allergy in ICD-10). — Central database of out of hours contacts (NHS Direct). — Central database of A&E consultations. — Central database of out-patient consultations. — Data linkage potential between diVerent healthcare datasets to allow more meaningful analysis of overall disease burden to individuals and populations and also to allow the study of risk factors associated with disease development and exacerbations. — In the light of such large variations, there is a need for on-going data surveillance, particularly for food allergy and anaphylaxis. — Quality of life measures being developed for the full spectrum of allergic conditions.
In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)? 11. This is likely to be large, but cannot reliably be measured at present because of the absence of relevant data collection (see above).
Treatment and Management
What is the effect of current treatments on the natural history of allergic disease? 12. There are currently no cures for allergic problems—rather, what we have is an array of non- pharmacological and pharmacological approaches which can, in most patients, help achieve symptom control and possibly result in some modification of the underlying disease course. 4 The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee, Worldwide variation in prevalence of symptoms of asthma, allergic rhinioconjunctivitis and atopic eczema: ISAAC. 5 European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996; 9: 687–95. 114 allergy: evidence
17 January 2007
What is the evidence-base for pharmacological and non-pharmacological management strategies? 13. Whilst the evidence-base for pharmacological treatment approaches is on the whole good for most commonly used preparations, there is less secure evidence for allergen avoidance approaches that are commonly recommended. There is also very little evidence in relation to important health services research questions about how best to structure care. 14. The shortage of capacity in allergy treatment capacity has led the public to look outside the NHS. This has resulted in the proliferation of questionable allergy practice in the field of alternative and complementary medicine, where unproven techniques for diagnosis and treatment are used.6
Is the level of UK research into allergy and allergic disease adequate? 15. There are currently no dedicated funding streams for allergies in the UK and there are also no charitable funding streams for researchers to draw on. Much of the existing generic funding available from the Medical Research Council and the Wellcome Trust has, for example, been directed towards basic sciences and translational research and there has as a consequence been very little dedicated health services research into allergy. This problem was highlighted in the recent Department of Health and Scottish Executive reviews into allergy services and the relative lack of evidence uncovered in relation to how best to provide care. In view of the scale of the problem, what is needed is provision of programme research grants to allow meaningful progress to be made.
What are the most promising areas of research into preventing or treating allergy? 16. There is a need for a dedicated Cochrane review group for allergy to allow relevant high quality evidence in relation to disease prevention, treatment and organisation of care to be systematically collated and periodically updated. Areas of research that need investing in include studying the role of dietary exposure in pregnancy and infancy, evaluating the role of prebiotics, probiotics, anti-oxidants, pasteurised milk and vaccination based strategies, amongst others, and various combinations of these, for preventing disease onset and progression. Research is also needed into educational initiatives aimed at primary care staV and also new models of delivering care such as General Practitioners with Specialist Interests in allergy.
Government Policies
How effective have existing Government policy and advice been in addressing the rise in allergies? 17. The number of allergy specialists is totally insuYcient to meet the need. Improved links are required between primary and secondary care. Increasing specialist capacity in allergy practice would improve diagnostic and treatment advice and would allow primary care teams to draw on an existing specialist knowledge base. 18. The only specific government advice that we are aware of relates to high risk mothers modifying their diets and those of their infants, but there was no proactive attempt to assess compliance with this and evaluate its eVectiveness.
How is current knowledge about the causes and management of allergic disease shared within Government? For example, — Do housing policy and regulations governing the indoor environment pay enough attention to allergy? — How eVectively are food policy and food labelling regulations responding to the rise in food allergies? 19. Current housing policy has not really considered the issue of allergy in any serious detail. The recent EU directive about food labelling appears to have been helpful in allowing food allergy suVerers to better determine the contents of pre-packaged foods, but there has been no attempt empirically to evaluate whether food allergy suVerers have found this advice helpful or satisfactory. Furthermore, issues remain about the adequacy of current labelling approaches. 6 Bielory L. “Complimentary and Alternative Medicine” Population based studies: a growing focus on allergy and Asthma. Allergy; 2002; 57: 6,455–8. allergy: evidence 115
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Patient and Consumer Issues
What impact do allergies have on the quality of life of those experiencing allergic disease and their families? 20. In some patients, allergic disorders are relatively short-lived and exert only a relatively minor impact on day-to-day life. There is however ample evidence that they can also be life-threatening, and in those with particularly severe allergy or substantial co-morbidity the concern is that they can impact on all aspects of day- to-day life. For those with food allergy, the whole household can be aVected and impairment in quality of life for young people can be comparable or even greater than those with diabetes. Living with the threat of possibly life-threatening reactions can be very worrying for all concerned.
What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? 21. A number of measures need to be taken, including: — Better undergraduate training for healthcare professionals which is based on an understanding of the needs of suVerers. — Similarly, better postgraduate training opportunities, particularly for GPs and their teams. — A national NHS e-library for allergy with a section also available to the public. — Map of Medicine for allergies which patients also have access to. — A dedicated patient helpline/website, linked to NHS Direct, for authoritative information being made available in a range of languages.
Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory? 22. No, as there are a number of diagnostic tests available which do not have any sound scientific basis—these are therefore unhelpful, and potentially harmful, as they can result in considerable unnecessary restriction of diet etc. Better regulation would certainly be helpful, accompanied with far better access to scientifically sound tests in primary care. 23. I acknowledge the contribution of Professor Aziz Sheikh (Allergy & Respiratory Research Group, Chair; Professor of Primary Care Research & development, University of Edinburgh) towards the above comments; additional contributions were made by Dr Mark Levy (Clinical Research Fellow, General Practice Section, University of Edinburgh; Editor-in-Chief, Primary Care Respiratory Journal), Professor David Price (GPIAG,7 Professor Primary Care Respiratory Medicine, University of Abderdeen) and Dr Dermot Ryan (GPIAG, Allergy Lead; Rhinitis Guidelines Working Party; Rhinitis Guidelines Committee; Royal College of Physicians, Allergy Working Party). While contributing to this response, it cannot be assumed that all of those named necessarily agree with all of the above comments. 9 October 2006
Memorandum by the Royal College of Paediatrics and Child Health (RCPCH)
1. Defining the Problem
1.1 Allergy and Intolerance Hypersensitivity or intolerance is an umbrella term that refers to reproducible symptoms or signs to a defined stimulus at a dose tolerated by normal subjects. It includes non-allergic hypersensitivity, such as lactose intolerance and reactions to caVeine, and allergic diseases such as eczema, asthma, food allergies, rhinitis, drug allergy, venom and latex allergy. In addition many people have a misconceived belief their child is allergic. Such individuals also required accurate assessment in an allergy clinic. 7 GPIAG: General Practice Airways Group. 116 allergy: evidence
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1.2 Origins of allergic disease A good deal is known about the immunological basis of allergy, but underlying causes of allergic conditions are more diYcult to understand. Changes in prevalence over the last four to five decades cannot be readily explained, although a number of theories have been proposed and most have focussed on early-life interactions between genes and environment such as allergen exposure in pregnancy and infancy, maternal and infant feeding practices, viral and bacterial infections in infancy, environmental tobacco smoke, pollutants, pet contact, family size and rural living. Family history is clearly an important risk factor for allergy. Twin studies have suggested that as much as 75 per cent of the risk of developing allergic rhinitis may be genetic. Family studies have identified a number of genes that predispose to developing both asthma and atopy. As in other complex conditions, genes interact significantly with each other and with environmental factors to aVect the risk of developing disease. Exposure to infections or allergens before and immediately after birth may be significant. Allergy is also less likely to develop in children with older siblings and in children brought up on farms or in close contact with animals. Breast feeding reduces the risk of infant wheezing and food allergy in infancy but may not reduce the chance of developing asthma or other significant allergies in later life. Maternal smoking during pregnancy and in the first few years of life increases the risk of asthma. Obesity also makes asthma more likely. The relative roles of allergen exposure and avoidance in the development of allergy are unclear and conflicting. For example, exposure to cats in infancy may induce tolerance and prevent the development of asthma and wheeze. Conversely, exposure to animals in a sensitised child may exacerbate wheezing symptoms. Similarly, prolonged breastfeeding and the use of hypoallergenic milk formulas has a transient impact on preventing the development of eczema and food allergy in infancy. It is currently unclear as to whether avoiding allergens or early exposure is the best recommendation for preventing the development of allergy.
1.3 The progression of allergic disease The progression of allergic disease is well documented. Indeed the progression from food allergy and eczema in infancy to rhinitis and asthma in mid-childhood is often described as the allergic march. Most food-induced symptoms presenting in infancy have resolved by three years of age. Cows milk allergy aVects about 5 per cent of children with a remission rate of 50 per cent per year for the first three years of life. Egg allergy aVects 2.6 per cent of children with 50 per cent remission at four to five years of age. Peanut allergy aVects 1 per cent of children, preschool children have an 18 per cent chance of resolution. Seafood allergy aVects 0.6 per cent of children with about 4 per cent giving a history of having outgrown their allergy. 50 per cent of children with eczema will have outgrown it by six years of age and two to three will have outgrown it by 14 years of age. Most asthma has its origins in childhood. More asthma persists through adolescence than is generally believed and even in those cases that remit many recur in adulthood. The prevalence of asthma in children aged 9–11 years is double that in adults from the same country and region, as is the prevalence of bronchial hyperresponsiveness. Wheezing illness is at its most frequent in the pre-school period with 50 per cent of children experiencing wheezing before the age of six years. The prevalence of wheezing illness drops from 50 per cent at age 7 to 18 per cent at age 11 and to 10 per cent at age 16. Clinical studies report up to 80 per cent of asthmatics lose their symptoms during puberty. After puberty asthma prevalence rises again—to 27 per cent by age 33. The pattern of disease in early life dictates the way in which it evolves through childhood. Thus paediatricians are in the ideal position to modify outcomes.
1.4 The rising incidence of allergy and high UK prevalence The reasons for the rising incidence of allergy and allergic disease are unclear, but have been associated with increasing aZuence. Worldwide variation in rates of atopic disease suggest that environmental factors are critical to the development of these disorders in childhood. Within the United Kingdom, atopic disease is significantly higher in Scotland and Northern England.
1.5 Gaps in establishing the overall disease burden In Britain, there is little reliable information at the national level about the nature and magnitude of the burden posed by allergic conditions and the costs that these incur. The ISAAC study estimated the prevalence of asthma, hayfever and atopic dermatitis in six to seven year olds and 13 to 14 year olds as part of a worldwide study. These data are limited by the validity of patient recalls of an allergy diagnosis (less so in the ISAAC study). The UK prevalence of food allergy and other allergic diseases are less well documented with no good allergy: evidence 117
17 January 2007 population-based studies of prevalence. Research studies looking at prevalence are often small and localised, making it diYcult to obtain an overall picture of the disease burden in the United Kingdom. A central funding body for allergy research would help to address this. Within medical practice, allergy as a disease entity is coded as one of 17 definitions on ICD 10. Allergic disease is also often coded under the organ specific manifestation such as eczema or asthma. These are complex conditions, where disease definitions are unclear or ambiguous and there is a lack of uniform methods of data collection. Allergic conditions often occur together. Co-morbidity has been studied in a number of settings. Figures for prevalence vary, partly because problems of diagnostic variability and ascertainment are multiplied when more than one case definition is applied. At the same time the severity of the combined problems are underestimated Allergic rhinitis is present in at least 75 per cent of people with asthma and increases the cost of their care and the burden of disease impacts exponentially on the suVerers.
PREVALENCE (%) OF COMORBIDITY FOR ASTHMA, ECZEMA AND ALLERGIC RHINITIS
Age (years) Number of diagnosed atopic conditions 13–14 2–15 16–44 1 332825 21598 3 422 At least one 52 39 35
1.6 The socio-economic impact of allergic disease An assessment of the burden of healthcare costs of respiratory allergic disease has been made at over one billion pounds per year. Asthma is a leading cause of hospital admission in children. Rhinitis significantly reduces quality of life, interferes with attendance and performance at school and results in substantial NHS costs. There are additional economic implications for parents also needing to take time oV from work to look after their children. Results of examinations held during the summer are significantly lower in hayfever suVerers. Children with hayfever may drop a grade as a result of their symptoms. The relationship between reduced final school grade results and reduced income generated once these children reach employment has added economic implications. Shopping for a child with nut allergy takes 39 per cent longer and increases the cost of the weekly shopping basket by about 11 per cent.
2. Treatment and Management
2.1 Current treatments—effect on natural history The majority of treatments currently employed in the UK centre on symptom control. EVective treatment of allergic rhinitis improves symptoms of asthma and reduces emergency treatment and hospitalisation for asthma. Allergen avoidance is also important in controlling symptoms once they have developed. Cochrane reviews have demonstrated the eYcacy of immunotherapy for the treatment of asthma and rhinitis Immunotherapy is the only treatment capable of modifying the natural history of the disease. For treatment of allergic rhinitis, it induces long term remission, prevents spread of sensitisation to other allergens and prevents the progression to asthma in children. Immunotherapy cures 95 per cent of patients with bee and wasp venom allergies. When a patient presents with allergic symptoms, accurate diagnosis and assessment of other allergic conditions reduces comorbidity. For example, detection of persistent sensitisation to egg and/ or aeroallergens in infants with eczema highlights a group at risk of progression to asthma, who may benefit from early intervention.
2.2 Evidence base for pharmacological and non-pharmacological strategies There is a good evidence base for pharmacological strategies, particularly for the management of asthma and rhinitis using inhaled and nasal steroids, antihistamines, bronchodilators and leukotriene receptor antagonists. The evidence base for non-pharmacological strategies, including allergen avoidance, is less clear. A Cochrane review of House dust mite reduction measures reported an improvement in rhinitis symptoms. 118 allergy: evidence
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This eVect is more pronounced in children than in adults. The relative lack of evidence for non- pharmacological strategies may be impacted by sources of funding for allergy research. Research into non- pharmacological strategies would be enhanced by a centralised source of allergy funding, independent of the pharmaceutical industry.
2.3 UK research into allergy and allergic disease The United Kingdom has a paradox of having excellent allergy researchers in several centres. Translating their research into clinical practice is restricted by a lack of centres for the practice of clinical allergy. As previously stated, there is no central funding body for allergy research. Investment in allergy research is therefore less than in other high cost areas. Allergy centres are therefore compelled to compete with higher profile translational research areas such as neurosciences, cardiovascular disease, obesity and ageing.
2.4 Research into the prevention and treatment of allergy Research into the prevention and treatment of allergy needs to focus on immune modulation and treatment in early life, to reduce the burden of disease and prevent the progression of the atopic march. Allergen avoidance as a principle of primary prevention has been shown to be ineVective and allergen exposure in infancy may be protective against the development of allergy. Further work needs to be done to establish this. Vaccines, prebiotics, probiotics and reduction of allergen exposure are all promising areas; as is the eVect of nutrition and potential for disease modification. The demographics of obesity mimic that of allergy. There is potential for exploring the relationship of allergy with the increase in obesity; also obesity prevention and its eVect on allergy.
3. Government Policies
3.1 Effect on addressing the rise in allergies Government policy and advice has been ineVective in preventing the rise in allergies. In 1999, the DOH recommended that pregnant mothers should avoid eating peanuts to reduce the incidence of peanut allergy. The United Kingdom was the only European country to make this recommendation. Surveys have suggested that the advice was not heeded by the target population, which indicates that the strategies employed by DOH to promote health are defective. In the event subsequent research has demonstrated that avoidance diets do not prevent antenatal allergen exposure and may, paradoxically, lead to an increase in the development of food allergy. Other allergen avoidance strategies for the primary prevention of food allergy (prolonged breastfeeding, use of hydrolysed formulas and avoidance of allergenic food) are relatively ineVective. A more secure evidence base is therefore needed before recommendations are made to the general public. Future recommendations will need to be clear and widely available. They will need active re-inforcement in order to be eVective.
3.2 How current knowledge is shared with the Government Within the allergy community, knowledge about causes and management of allergic disease are shared through the British Society for Allergy and Clinical Immunology. Knowledge about allergic disease aVecting children is shared through the British Paediatric Allergy, immunology and infectious diseases subgroup of the Royal College of Paediatrics and Child Health. Allergic disease is complex and management initiatives need to be considered within the full context of allergic disease. Both of these organisations should have a wider role in informing government policy. Information appears to be fed through to the government on a piecemeal basis. There is a lack of representation of the needs of allergy patients and allergy services at a government and Department of Health level.
3.3 Housing policy Housing policy currently focuses on energy saving. This conflicts with the needs of allergy patients because indoor allergen and pollutant levels increase as air exchanges decrease. Patients with allergies need improved ventilation systems in their houses. Indoor air humidity also needs to be taken into account. The United Kingdom has a very damp climate and high humidity levels inside houses, compounded by washing and allergy: evidence 119
17 January 2007 cooking in homes with reduced ventilation lead to high levels of humidity, pollutants such as nitrogen oxides, volatile organic compounds etc, moulds and house dust mite in British homes. Both increased damp and house dust mite levels are significant risk factors for the persistence of symptoms in children with asthma. The type of building (houses vs. flats), ventilation system and presence of a basement all have major implications on respiratory symptoms, atopy and house dust mite infestation. Building construction aVects both respiratory morbidity and allergic sensitisation through development of disease and worsening of symptoms.
3.4 Food policy and labelling regulations
Policy for food labelling is now directed by the European Union and is consequently relatively responsive and allergy aware. The Food Standards Agency enforces food labelling regulations and operates with allergy consumer input from the Anaphylaxis Campaign. Recent changes to the recommendations for food labelling have improved the information available to consumers, but are not patient centred and, in some cases, has increased the confusion experienced by allergy suVerers. Alternative foods for allergy suVerers are expensive and may not be readily available. 56 per cent of food items indicate that they contain traces of nuts, there are no substitutes for 18 per cent of items and 9 per cent are of poorer quality. The recent campaign for healthy eating in schools has not taken into account the needs of peanut allergic children. Recommending that nuts should be increasingly available as a healthy snack from vending machines increases the risk of allergy suVerers having an acute reaction by inadvertent exposure.
4. Patient and Consumer Issues
4.1 Impact of allergy on quality of life
Quality of life of children with peanut allergy is more impaired than in children with diabetes. Teenagers with allergic rhinoconjunctivitis experience impaired quality of life due to local and systemic symptoms, limited activity and emotional and practical problems. 7 per cent of children are aVected by more than one allergic condition. The impact on quality of life of co-morbidity is diYcult to study. For example, the eVect of rhinitis and sleep disturbance on school performance and the impact on exam results and career attainment is not well documented. The timing of exams are important, children with summer hay fever will drop a grade when they sit their exams which are usually scheduled for the middle of the grass pollen season. Venom immunotherapy oVers improved quality of life over provision of rescue medication alone in patients with severe reactions to wasp stings.
4.2 Better education of public and patients
The fundamental problem is that a patient often suspects that they have an allergy, but, because of lack of access to accurate allergy diagnostic procedures, they are unable to obtain accurate and eVective advice (similar to a patient, suspecting they might have cancer, the first step would be to be referred somewhere where an accurate diagnosis can be made, before eVective treatment can be given). We have eVective treatments, but there is a gap in access to accurate allergy diagnosis forcing patients to access alternative, inaccurate and inappropriate advice through complementary medicine. This is compounded by misconceptions in the popular press. A programme of health promotion and health education and an increased awareness of allergy is needed within the general population, patient population and primary care. For general practitioners, there is a lack of teaching in medical schools at undergraduate and postgraduate levels resulting in a significant knowledge gap and a need for GP education programmes supported by a network of specialists. Currently, there is an information vacuum allowing pharmaceutical companies to provide promotional material inappropriately (for example, recommending the use of sedating anti-histamines for the treatment of hay fever). It also leaves appliance companies relatively unregulated in relation to claims about health benefits such as for vacuum cleaners, air filters, ionisers etc. The public tends to get an unbalanced view of allergy and the options available for treating it. There is a need for a centrally funded allergy awareness strategy, which is not commercially linked. A schools education programme would improve allergy awareness for children. 120 allergy: evidence
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4.3 Regulation of private clinics Legally constituted regulation is imposed on medical practitioners by the General Medical Council, whether they work in the private sector or for the National Health Service. Private medical clinics are increasingly incorporating governance standards used within NHS clinics and hospitals. Children with allergic disease are significantly more likely to seek advice from alternative medicine practitioners than children with other illnesses. This may reflect a lack of adequate service provision for these children or insuYcient knowledge regarding the management of allergies in primary care. Non-medically qualified practitioners are able to freely practice subject to minor limitations. This unregulated situation has existed since the 16th century. There is considerable variation in the levels of professionalisation within the Complementary and Alternative Medicine world. Osteopathy and chiropractic are the only two complementary professions with statutory regulation. Other practitioners, such as herbalists, homeopaths, Chinese medicine practitioners and accupuncturists are regulated through voluntary professional organisations and are able to make unsubstantiated claims without challenge. Nutritionists without formal dietetic training who recommend dietary exclusion in infants based on unfounded tests are a particular problem. Unregulated peanut desensitisation has the potential for severe adverse eVects. Kinesiology, vega testing and hair analysis as forms of allergy testing have no scientific rationale and are not valid diagnostic procedures.
4.4 Paediatric allergy training and service provision Allergic disease has its basis in childhood. As a consequence the management of allergic disease requires an understanding of the developmental aspects of the child including physiology, nutrition and immunity. It is therefore regrettable that there are very few paediatric allergy specialists in the UK; nine specialists overall of whom six are based in London. Furthermore there are no established training programmes for paediatricians wishing to become specialists in allergy. The College of Paediatrics Special Advisory Committee is attempting to correct this but currently only two centres in the UK can provide the training to obtain the competencies required by a paediatric allergist. More tertiary centre based paediatric allergists are required—not only to treat the most complex cases but to provide research into the paediatric aspects of allergic disease and to provide the necessary training for future generations of paediatric allergists. While much paediatric allergy is dealt with at primary and secondary care level, tertiary specialists can fulfil a key role in providing a network for guidance and support to these clinicians.
Reference List [not printed] 10 October 2006
Memorandum by the Immunology SAC, Royal College of Pathologists Immunologists and allergists provide specialist clinical allergy services in the UK, and are the only medical specialties with extensive training in the immunological basis of allergy and the clinical care of patients with allergic disorders aVecting all organ systems. Allergists devote all their professional time to the management of Allergy, immunologists often have other responsibilities and varied job plans, but most devote substantial parts of their professional time to the provision of allergy services. The remit of the House of Lords Sub-Committee is very wide-ranging and will require a thorough review of a vast amount of evidence. The published evidence on conventional practice, and that on complementary therapies will need to be subjected to proper scrutiny for quality, lack of methodological flaws, exclusion of placebo eVect and reproducibility before being used as evidence for public policy decision-making.
1. Defining the Problem
1.1 What is allergy? What is the difference between allergy and intolerance? 1.1.1 Allergy—Immunological disease mediated by the Immune system—it has a limited number of stereotypic manifestations which are dictated by the immunological mechanisms underlying Mast cell activation. It has a genetic basis, but the expression of disease is influenced by the environment and reproducible allergen-triggered, IgE antibody-mediated disease mechanisms can be identified and give rise to clinically disease. allergy: evidence 121
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1.1.2 Intolerance is a catch-all term for any adverse eVect experienced by an individual which is often mistakenly attributed to allergy but for which there is no reputable evidence to suggest that it is an immunological adverse reaction to foods or medicines. Some “intolerances” such as food-induced migraine are probably pharmacological actions of the food. Intolerance is therefore a state of sensitivity to a specific environmental component which manifests within an individual, objectively or subjectively, as a reproducible unpleasant reaction upon exposure to that component. 1.1.3 Detailed nomenclature can be found at http://www.eaaci.net/site/nomenclature.pdf. 1.1.4 Much information including practice parameters/position statements and expert evidence-based guidelines on the management of allergic disease can be found at the websites of allergy/Immunology professional societies such as www.BSACI.org.uk; www.aaaai.org; www.eaaci.net.
1.2 Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such high prevalence of allergy? 1.2.1 The incidence of many forms of allergy is clearly rising and the rise does not appear to be related to better reporting and diagnosis, but the reasons are poorly understood. Epidemiological meta-analysis of the existing data has already been published as an appendix to the DH (Department of Health) report into the provision of allergy services, but caution is needed in comparison of results in diVerent countries. The lack of systematic meta-analysis is hampered by the variable quality of the data and expert large scale epidemiological studies are required—the UK is uniquely well-placed to deliver these studies through the NHS and associated research but the lack of investment in the future training of specialists practicing allergy and immunology and the diYculties pursuing an academic medical career (likely to result from a potential reduction in overall funding associated with the Culyer report) are likely to impair this important work. 1.2.2 It is not known why the UK or anywhere else has a rising incidence of allergic disease—although there are many hypotheses all of which remain unproven. Despite their plausibility, the link is still speculative for most. The DH review highlighted the gaps in evidence at present.
1.3 What is and what is not known about the origins and progression of allergic disease? 1.3.1 There is much work still to be done on the genetic and environmental predisposition to the development of allergic disease, and strategies to prevent its development or modify its expression in individuals. In the absence of a national strategy, the failure to support and develop academic and NHS research into allergic disease may seriously impair future understanding of the issues in the UK. There is exciting and preliminary work suggesting that the “Allergic March” in children can be prevented by early immunotherapeutic intervention. 1.3.2 What is known: — Genetic influences (some of). — Environmental influences (some of). — Immuno(dys)regulatory mechanisms (some of). — Intrauterine and postpartum influences (some). — The existence of the “allergy march”. — Age influences on disease presentation. 1.3.3 What is not known: [Sic] — Why predominance of diVerent clinical presentations at diVerent ages? — Why does some atopy manifest as clinical disease and some remain latent? — What factors determine mild vs. moderate vs. severe allergy. — How to predict the severity of the next reaction in an individual in order to tailor individual treatment plans and risk-assessments. — How to prevent allergy developing or modify its severity. — There are many putative factors with varying levels of supporting evidence. — Genetics. — Hygiene hypothesis (much conflicting evidence). 122 allergy: evidence
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— Pollution (personal and environmental). — Lifestyle eVects (homes, pets, diet etc). — Climate—eVects on home environment—eg for House dust mite.
1.4 What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 1.4.1 Evidence has delineated a substantial and underestimated disease burden in the UK. Further work is needed to develop robust evidence base with validated measures, this is unlikely to occur if the specialities of Allergy and Immunology are not developed as part of a national strategy to improve NHS service and research provision, as well as providing the infrastructure for the proper gathering of such information. 1.4.2 There are likely to be significant gaps in robust mechanisms for workload recording/capacity in primary care and secondary/tertiary care. These will be essential for teasing out allergy workloads from workload recording of related/overlap diseases—especially in Immunology centres as opposed to pure Allergy centres. Improved coding necessary to collect this information in a sophisticated and standardised way is essential, as current ICD 10 and Payment by results codes are currently insuYciently detailed. It is hoped that NHS data collection will gradually be improved by these drivers. 1.4.3 There are many barriers which need to be overcome—recognition at local/commissioning level that allergy is a significant problem for the NHS, improved allocation/prioritisation of resource for allergy research, and successful establishment of the relevant NHS IT infrastructure to support improved data collection which is currently underway.
1.5 In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)? 1.5.1 The assessment of disease burden or socio-economic impact with any reliability is also very diYcult, and diYculties in validation of presumed measures of economic impact. It is clear however from the evidence presented to the DH Review, and evidence from patients, patient support organisations, allergists, immunologists, GPs, nurses and other medical specialties, that allergy in all its forms has considerable impact on the lives of patients, disrupting schooling, work, and general quality of life, as well as the risk of death and other morbidity from more serious forms of allergy and asthma.
Treatment and Management
2.1 What is the effect of current treatments on the natural history of allergic disease? 2.1.1 There is much published evidence for the eVectiveness of interventions by allergists/immunologists (see AAAAI “Consultation and referral guidelines citing the evidence: How the allergist-immunologist can help”—on www.aaaai.org) particularly for allergen avoidance strategies, immunotherapy and treatment of asthma, hay fever and specific food allergies. A review of meta-analysis of eVectiveness of treatments has been published as an appendix to the DH report. This highlighted the need for more research and gaps in the evidence. This will require the support and development of national centres of expertise, a network of regional centres of excellence in NHS service provision (primarily through allergists and immunologists and multidisciplinary team working) and improved service provision and data collection in primary care. Much of NHS treatment in all specialties is of necessity based on expert opinion and experience in the absence of randomised double-blind controlled trials in many areas. While we all strive to correct this, and NICE may be given the task of reviewing evidence to identify interventions for which there is evidence of ineVectiveness (in a limited number of interventions, not involving allergy to date). The select committee must remember that lack of evidence of eVectiveness is not evidence of lack of eVectiveness. The two are often conflated in policy decision-making, often erroneously. 2.1.2 Pharmacotherapeutic options currently available are unlikely to have significant eVects on natural history of disease other than primarily managing symptoms. The same may well be true for allergen avoidance/ environmental modification measures. allergy: evidence 123
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2.2 The data on complementary interventions
2.2.1 Research into complementary interventions is inadequate and this is a highly contentious issue. While acknowledging that the evidence base for many conventional treatments is sub-optimal, this should not influence the critical scientific evaluation of the quality of evidence for complementary interventions, which is often regarded as poor by most scientific standards. 2.2.2 To our knowledge there is only one chair of Complementary Medicine in the UK (at the Peninsular Medical School in Plymouth ( http://www.pms.ac.uk/compmed). 2.2.3 “Vega” testing has recently been examined as complementary diagnostic technique without demonstrating eYcacy (Lewith et al BMJ 2001;322:131-134 ). Interventional studies are often flawed and diYcult to interpret due to methodological biases. 2.2.4 If necessary the committee should consider clearly argued critiques of the evidence for the more esoteric complementary therapies from a “conventional” medical/scientific standpoint, as well as the counter arguments of the proponents of esoteric therapies to gain an insight into the controversial nature of these debates. 2.2.5 The committee should familiarize themselves with the position statements on complementary therapies of the RCP (Royal College of Physicians), AAAAI, BSACI (including that submitted to the DH review) and other allergy and immunology organisations for the expert consensus view of the evidence for some complementary therapies. 2.2.6 Most conventional medical practitioners and professional societies have reservations about the quality of evidence for many complimentary investigations and acknowledge the diYculty in producing interventional studies of suYcient power which are not subject to error and biases or the placebo eVect (even if the placebo eVect is a very important tool in making patients feel better and an important part of patient care, even in conventional medicine). 2.2.7 There is some recently published data of doubtful validity to suggest that IgG antibodies may predict food intolerances but this is controversial and is not confirmed by other studies. Interventional studies using dietary avoidance may have methodological errors that may lead to biases which make them unreliable.
2.3 Evidence base for Pharmacological and non-pharmacological Management Strategies
2.3.1 To a certain extent the evidence base has been examined in the appendices to the DH review. This is far too large an area to review in this submission but we would direct the select committee to the evidence submitted to the DH enquiry by the BSACI and others, and to the websites above, for expert consensus opinion. 2.3.2 The evidence base for most standard pharmacotherapeutic options—corticosteroids, H1blockers etc. have a significant body of evidence underpinning their beneficial use in allergy. 2.3.3 Adrenaline in anaphylaxis—Expert opinion and extrapolation from retrospective observations, including the UK Rescusitation Council Guidelines agree about the likely benefits, but objective evidence is lacking because of the obvious diYculties which preclude the studying of its eYcacy in randomised controlled trials. It would be unethical not to administer adrenaline to a patient with anaphylaxis. There is also the distinction between the end-points of eYcacy for prevention of fatalities and eYcacy in rapidly terminating an episode and reducing morbidity which must be considered. This is a good example of lack of evidence of eYcacy not being equated with evidence of lack of eYcacy. 2.3.4 Anti-IgE—There is evidence of eYcacy in severe asthma, and in increasing the dose tolerance of patients with food allergy, and it may have a role in other allergic disorders. Its place in routine practice in the UK is, as yet, unclear although there is much potential in other areas of allergy practice. 2.3.5 Non-pharmacological: Allergen avoidance: Once again there are diYculties in interpreting the existing evidence. Intuitively this is a “common sense” measure which ought to be highly eVective, and there is data to demonstrate this in some food allergies such as peanut sensitivity. Objective evidence of eYcacy in most sorts of aeroallergen allergy eg House Dust Mite Sensitivity is diYcult to obtain, most likely due to a lack of comparability between diVerent studies because of methods and patient selection. 124 allergy: evidence
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2.4 Is the level of UK research into allergy and allergic disease adequate?
2.4.1 Clearly not, even though much excellent research is done by a small cadre of specialists—see appendices to DH Review July 2006 and comments above. More importantly, there is reason to believe that the future of such clinically-based applied/translational research is precarious in view of the small number of specialists and lack of training opportunities. 2.4.2 Both specialties lack manpower and have insuYcient training posts, leading to current and future diYculty with recruitment and retention of clinical and academic specialists. A strategy is required to facilitate eVective NHS research into the cost-eVectiveness of diVerent methods of service delivery and advance the treatment and understanding of allergic disease in general. These two aspects (service provision and research strategy) cannot be easily divorced in a highly specialised clinical service area with a small workforce. 2.4.3 Answers to UK specific problems will not be forthcoming without support for the retention and development of a cadre of specialist allergists/immunologists, and results from other countries may not always be relevant to a UK population.
2.5 What are the most promising areas of research into preventing or treating allergy?
2.5.1 There are many promising interventions including: — Conventional allergen desensitization. — New forms of immunotherapy with T cell modulating allergens, modified allergens and use of anti- IgE antibody therapy outside of asthma. —DiVerent routes of administration such as sublingual immunotherapy. — Use of conventional allergen immunotherapy in children to prevent the development of asthma is promising. — Bradykinin- and tryptase-inhibiting drugs and other potentially useful interventions are in development. — Many of these experimental interventions have been championed by UK researchers and clinicians and the continuation of this in the future is in jeopardy without a coherent strategy to secure specialised services and consequent clinical applied research and development. 2.5.2 There is also a need for research into: — Service delivery/deficiencies/needs/gaps issues. —EYcacy of models of patient/profession education. — The natural history of food allergy is poorly understood although we have some preliminary understanding. We suspect that some people with nut allergy outgrow their sensitivity with time but cannot predict who will do so. We also do not know if these people have a risk of re-sensitisation. There are more questions than answers at the present time.
3. Government Policy
3.1 How is current knowledge about the causes and management of allergic disease shared within Government?
3.1.1 We are not aware of eVective sharing of knowledge or appropriate input into government policy in these areas other than the DH review and select committee report, although professional societies, patient support groups and Royal Colleges all responded to consultations and reviews when asked. This is a situation that has been of concern to the Royal College of Pathologists for some time in many areas of governmental activity, and it is clear that decision-making will be much improved with eVective stakeholder and expert input. A mechanism is needed to facilitate this. There exists a body of experts in the Royal Colleges, willing and able to assist in the formulation of government policy yet often there appears to be no mechanism for ensuring that this resource is eVectively and routinely tapped. The Royal College of Pathologists keen to act as a resource for identifying individuals with the appropriate expertise in any given area. allergy: evidence 125
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3.2 How effective have existing Government policy and advice been in addressing the rise in allergies? 3.2.1 The committee is not aware of any evidence of such action or evidence of its eVectiveness. Part of the problem lies in a lack of suitable evidence in relevant areas, for example into allergen avoidance strategies for infants to potentially reduce the incidence of food sensitisation. 3.2.2 We feel that government policy to date has not been eVective in addressing the needs of patients with allergy. The DH concluded that there was a considerable burden of allergic disease, that more specialists were required, and that provision of services was inadequate and geographically unequal and needed to be addressed, perhaps by networking. The report of the DH Select Committee did highlight the need for a network of allergy services throughout the UK, the need for additional training positions and the need for expert review of the eVectiveness of interventions perhaps through NICE. Unfortunately to date there is no obvious mechanism or driver to achieve this. 3.2.3 One key problem in allergy is how to engage local health commissioners to prioritise the establishment of adequate local allergy services in the face of all the other centrally driven demands on their budgets, such as the Quality and Outcomes frameworks for General Practice and Cancer and Heart Diseases National service frameworks, NICE guidance and other drivers. Care and education of patients with allergic disease and continued NHS research and development of new treatments and interventions is unlikely to improve significantly in the absence of such a driver.
3.3 Do housing policy and regulations governing the indoor environment pay enough attention to allergy? 3.3.1 We are not aware of evidence that housing policy can impact on allergy development or treatment unless it is proven that a patient is sensitive to a controllable environmental allergen such as mould spores or dust- mite. This may be of more relevance to work environments where we believe that protection against the development of occupational allergy is often covered by Health and Safety legislation.
3.4 How effectively are food policy and food labelling regulations responding to the rise in food allergies? 3.4.1 Food labelling is very important—some clear steps have been taken to make labelling mandatory including FSA documents but much more action needed (see http://www.food.gov.uk/safereating/ allergyintol). The FSA 2002 report “Adverse reactions to food and food ingredients” has already examined some of the issues on this topic). One major diYculty is knowing what the minimum threshold for labelling should be, and how to risk-assess this—a few individuals could potentially be sensitive to trace amounts of rare allergens, others may not. This is a diYcult issue requiring much careful thought. The role or risks/benefits of genetically modified foods is essentially unknown. 3.4.2 While food allergy must be taken seriously, some express concerns that an inappropriately low threshold for use of hazard warnings may be problematic. This problem impacts on patients who regularly report diYculties with selecting allergen-free foods and complicates the interpretation of supermarket labelling— where foods which are apparently very unlikely to contain an allergen are labelled as a risk, but the assessment of the level of risk is unclear. Some evidence based consistency and guidance is required.
Patient and Consumer Issues
4.1 What impact do allergies have on the quality of life of those experiencing allergic disease and their families?
4.1.1 There is much supporting evidence demonstrating that quality of life is impaired by every type of allergy from rhinitis to food-related anaphylaxis, and that allergy impacts adversely on many aspects of daily living. This may be addressed by better services support and advice in primary care, probably best supported by specialist hospital centres with extensive and up-to-date expertise. Much of this work is provided by patients support agencies and charities in the absence of easy access to expert consultations with allergist or immunologists. 4.1.2 There is preliminary evidence that management by an expert team is of benefit and improves patient outcomes but more work is required. 126 allergy: evidence
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4.2 What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? 4.2.1 A lot could be done to improve availability of information and advice from professional as well as informed lay organisations, but much allergy advice requires to be individualized and the construction of appropriate local information is dependent on local medical expertise in allergy which is scarce. 4.2.2 Allergy and immunology centres provide extensive patient support. This includes information, training in the use of rescue medication and expert assessment of the patients’ individual needs. A recent publication in the BMJ suggested that EpipensTM were oversubscribed such that the putative cost of each putative life saved was 20 million pounds, however this point of view is flawed because it ignores the benefits of proper treatment plan in managing anxiety, preventing morbidity and reducing symptoms. Expert risk-assessment and research into improved prognostic markers by expert units is required in order to minimise this cost to the NHS and ensure that rescue medications and therapy are administered in a cost-eVective and clinically appropriate manner. It is unlikely that we can rely on non-expert assessment in primary care without clear national evidence-based guidelines which will need to be supported through a local expert allergist/ immunologist. 4.2.3 Nationally, a lead needs to be taken by allergist/immunologists, to create national service standards, create a workable network of NHS allergy services with clear referral patterns and community outreach— including support for education and training in primary care. 4.2.4 Web-based guidance and information—often including that of some patient support groups—is not quality-assured and often mix complementary approaches and conventional advice, which can lead to confusion.
4.3 Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory? 4.3.1 Regulation of non-NHS clinics and over-the-counter treatments for allergy is not adequate—extensive evidence that it leads to direct harm to individuals is lacking, but there is clearly a legitimate concern that ineVective or misleading advice may be harmful, costly and may divert patients from eVective evidence-based interventions. High street stores or private centers may oVer complementary diagnostic testing with unproven techniques. 4.3.2 POCT (point-of-care-testing or near-patient testing) is a major potential problem even with conventional evidence-based assays when oVered in a context of inadequate quality assurance procedures, and by staV who do not have the clinical training or expertise to properly interpret their significance. A specific IgE test which is oVered without evidence-based expert assessment of the pre-test probability of allergic disease is worthless and potentially misleading. This is potentially as great a problem as that of the use of un-validated complementary tests of doubtful value. A positive test is not the same as the presence of a clinically important allergy or vice versa. We do not feel that a policy of “caveat emptor” is appropriate in health policy where there is an eVective evidence-based conventional intervention, or where it may lead to harm, and feel that a proper regulatory framework is required. 4.3.3 Hospital laboratories oVering diagnostic allergy tests are required to submit to a regime of inspection against quality standards in order to be able to oVer NHS diagnostic services. The same must apply to other providers and the government should assemble an equivalent policy on the basis of an expert review of the evidence. 9 October 2006
Memorandum by the National Allergy Strategy Group
Introduction 1. Allergy is a national health problem. There are no class, and no material regional, diVerences in its distribution. The burden of need falls equally across the population, and is substantial. It therefore requires a national eVort to secure fair access to appropriate services. This has not been forthcoming and there is substantial unmet need. allergy: evidence 127
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2. The NHS is now organized to provide its services through regional and, to a greater extent, local structures—Primary Care Trusts (PCTs) hold 85 per cent of budgets. One major problem, therefore, is how to address a national health issue which has not been addressed previously through a devolved NHS. 3. Allergy presents a problem of high need, low provision and hence a substantial service gap. 4. The consequence is that a very large number of people are being treated without a correct diagnosis or in the wrong way (for example treating symptoms rather than diagnosing the allergy and avoiding the allergic trigger). 3. The DH has conceded the problem. But the Department proposes to rely (even more than previously) on local and regional agencies to provide solutions. Yet, as DH has also conceded, PCTs know more or less nothing about allergy and most have no local expertise to call on and no information on the allergy needs of their population. Specialist allergists are needed to lead change, yet these are few in number and there is no investment in training to provide more of them for the future. How in this situation can the NHS be helped to orchestrate a national response? 5. Allergy presents today a clear and present challenge in this respect. But through time other new diseases will also require a national response from a devolved NHS. In this sense, allergy might be seen as presenting a test of how the NHS in the future could face up to future health challenges. At the very least, some way needs to be found to: (a) get more doctors (and other health care professionals) with the relevant expert training into service quickly; and (b) set up pilots or demonstration projects, showing what a model new service could deliver, from which the rest of the service can learn.
Effect of lack of service on research 6. Although this is much needed the UK produces little clinical research in allergy. Lack of NHS service results directly in absence of research capacity. Research requires a specialist service with large cohorts of well studied patients and clinicians with expertise in centres where research is a priority. This in turn requires clinical leadership in both adult and paediatric allergy. The UK has a tiny specialist workforce (there are only 26.5 whole time equivalent consultants in allergy)—for a huge burden of disease (allergy aVects 20 million people of whom about seven million require specialist help). 7. For the reasons set out above, many answers to the questions posed in the Terms of Reference are going to be equivocal. NHS staYng/expertise/clinics/data systems/ modes of treatment etc do not, for the most part, recognise allergy. And so, the basics are not there for the NHS to be a resource for knowledge generation about allergy. Information does exist, but in small pockets, where there are specialist allergy centres, and bodies such as the British Society for Allergy and Clinical Immunology (BSACI) have collected and analysed the published data.
Consequences for patients 8. People with allergy (or who think they or their child have allergy) are having to make their own judgments about what to do. This in turn has several consequences: — unregulated and sometimes dangerous private practice; and — failure to make an accurate allergy diagnosis. Both false positives (labelling a problem as allergy when it is not) and false negatives (failure to recognize or even consider allergy) are common—this inaccurate diagnosis results in bad management and ongoing disease. The need for diagnosis is central. Across the NHS, allergy diagnosis is not being made, because staV in primary and secondary care are not trained to do this. Investment in expertise in allergy is required to make this possible. 9. Estimates of the numbers of patients where allergy diagnosis is required and where specialist referral is needed are available (see Nature and Extent of Allergy in the UK, BSACI 2006). The current capacity of all NHS allergy clinics is only about 2 per cent of those needing hospital referral (not allowing for the fact that many of the allergy clinics run by consultants in other specialties, deal with limited areas of allergy and do not 128 allergy: evidence
17 January 2007 have the expertise or facilities, to undertake more complex investigation) (An NHS Plan for Allergy: Making a Start, NASG 2003, information prepared for the Health Minister). 10. The most serious problems occur for people with multiple allergy (allergy expressing itself in several diVerent ways eg eczema, asthma, anaphylaxis etc)—and for severe allergy.
Responses to Specific Questions
What is allergy? 11. Allergy is described in the Royal College of Physicians (RCP) Report “Allergy the unmet need” chapter 1, p 3–6. Allergic diseases are wide ranging and cross the traditional organ based specialties within medicine. 12. It is important also to consider what is allergy practice. What does an allergy clinic deal with? This is not restricted to diseases mediated by allergic antibody (IgE), but depends more on presentations of illness, rather than the mechanism. Allergy services deal with many diseases unrelated to IgE, such as non allergic rhinitis, forms of anaphylaxis, angioedema, tongue swelling, drug “allergy” and food intolerance and have an important role in excluding allergy as a cause of disease. 13. The other aspect is the additional value oVered by an allergy service. A particular disease might be appropriately dealt with in other parts of the NHS (eg asthma in primary care or by a respiratory physician where the focus is on drug treatment to control symptoms), but what an allergy service adds is the diagnosis/ management of allergy. For the most part this is not taking place in the rest of the NHS. Because allergy commonly has multiple manifestations, the ‘added value’ of an allergy specialist is also in being able to deal with the whole patient in a single service, rather than picking oV symptoms one by one and requiring referral to a series of specialists.
What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 14. An assessment of the burden of allergic disease in the UK was undertaken by BSACI in 2005 for the DH review of Allergy services, 2006 (“Nature and Extent of Allergy in the UK”). This was evidence-based using published data on epidemiology for each disorder where allergy might be involved, and severity, complexity and co-morbidity (several conditions occurring together in an individual). 15. From these data, service implications could be calculated: first, the number which could be treated by self care or in primary care with symptomatic treatment without need for a formal allergy diagnosis and the number where an allergy diagnosis was needed; and second, the number which could be managed in primary care (assuming the conditions required to improve allergy knowledge were met) [13 million people] and the number where referral to an allergy specialist was required [up to seven million]. 16. Despite the gaps in information, therefore, a count can be made of the amount of allergy. BSACI data shows that there are (47 million disease episodes or (20 million people who have a disorder where allergy may be involved. 17. Gaps were evident for: (i) Prevalence of urticaria, angioedema, drug allergy and latex allergy and there was incomplete data for anaphylaxis of any cause. (ii) It is also not known how many people falsely believe they have allergy and act, or are encouraged to act, as if they do so. Or their doctor takes action without a proper diagnosis. Important areas here are drug and food allergy, with medical and cost implications from incorrect diagnosis. The number wrongly labelled is likely to be in excess of seven million people for food allergy and several million for penicillin allergy alone. (iii) In a proportion of these, investigation to exclude allergy needs to be undertaken, so that appropriate management can be put in place. No estimate is available. (iv) There is also insuYcient information to suggest estimates of the numbers of people in the country who have an illness with an allergic cause which has been left undiagnosed. (v) Whilst there is considerable data on aspects of co-morbidity taken from the perspective of a single disorder (especially for rhinitis/asthma/eczema), there was no data in other areas. Documentation of the extent of multiple allergy (the number of diseases in the same patient) is not available. allergy: evidence 129
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(vi) There are several newly emerging allergies, and absence of data capture on these, for example, sesame and fruit allergy. There is now data on peanut allergy, the epidemic of the 1990s, but little information on other nut allergies. (vii) NHS statistics on allergy are lacking. (a) This is partly due to the failure to “code” allergy work. An allergy code was introduced in 2005 but has only been adopted in the few specialist allergy centres, and even there only applies to day case work. (b) This is also due to failure to recognise allergy across most of the NHS. And, even when recognised, recording of allergy is not mandatory in GP data systems. (c) NHS statistics on hospital admissions are available for a few conditions (with the caveat of under-recording, so failure to make the allergy diagnosis). Anaphylaxis admissions have risen seven fold in 10 years (Gupta et al 2004) but the absolute numbers give no indication of the real extent of the burden, as most anaphylaxis is treated in A&E, and does not appear in NHS admission statistics. (viii) EVect on Quality of Life. There are data, but most of this is anecdotal although compelling, from the patient organisations, Anaphylaxis Campaign and Allergy UK, who receive thousands of calls to their help lines which reveal eVects on quality of life from (i) failure to get medical help and (ii) coping with the disease. (ix) EVects on cost to NHS from failure of allergy diagnosis hence appropriate management. Estimate of direct/visible costs of NHS care can be made. The eVects on patients and on the cost of failure to diagnose are of an order of magnitude greater. Avoidance of the allergic trigger can ameliorate further acute disease episodes, well documented for food or drug allergy (see BSACI paper, EVectiveness of allergy interventions, 2006). 18. The major reason for these gaps in data is the lack of NHS specialist services in allergy, combined with lack of knowledge and awareness of allergy in primary care. Without a service base—particularly given the way Government research priorities are so closely aligned to clinical emphasis—there is no eVective research and data base from which to build.
In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)? 19. The same issues apply as above: one needs a service to make a diagnosis before impact can be measured scientifically. Some data is available for certain disorders eg nut allergy, venom allergy. Nut allergy causes more stress for families than a diagnosis of diabetes (Avery et al 2003). Bee or wasp venom allergy can cause life threatening anaphylaxis, a common symptom of which is a feeling that the patient is going to die. This fear is reduced by allergen immunotherapy (Oude-Elberink et al 2003), a treatment which is highly eVective, “switching oV” the allergy, yet it is hardly available to UK patients. However, Allergy UK and Anaphylaxis Campaign, can give extensive qualitative data on this, from their help lines. Allergy leads to huge stress and anxiety, unnecessary illness and loss of time from work or school, and is exacerbated by the failure of the NHS.
Is the level of UK research into allergy and allergic disease adequate?
Basic and clinical research 20. The major problem with allergy research in the UK is that it lacks a clinical or human resource base. Basic research relies on a few talented individuals. Clinical research requires clinic capacity, excellent clinical practice and clinicians whose main focus is on allergy, enabled to investigate well worked up patients in suYcient volume for expertise in patient management to be built up. 21. Basic research. There is excellent basic research into allergy in UK, where we are world leaders, but this is limited to a few centres, and dependent on a small number of senior academic staV. Its continuation is not guaranteed and the situation is fragile. The loss or retirement of one or two research leaders will greatly diminish our research base. 22. Clinical research. There is a serious lack of clinical research—even fewer centres, than academic centres in allergy related research—and need for substantial expansion here. 130 allergy: evidence
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23. Examples follow: At what might appear to be a very basic level, information on the value and interpretation of diagnostic tests is needed. Most doctors do not know how to interpret these tests; thinking, incorrectly, that a positive equals an allergy diagnosis. Clinical research is necessary to throw light on this eg in nut allergy, a “grey area” has been identified in the so called “positive” range, where 50 per cent of patients are allergic but 50 per cent are tolerant (Clark & Ewan 2003). Another development is to identify the level in a test result above which nearly all patients will have allergy (Sporik et al 2000; Hill et al 2000). There are other examples eg studies on how best to manage nut allergy with evidence on eYcacy (Ewan & Clark 2001; Ewan & Clark 2005). Such evidence can then be rolled out into clinical practice across the NHS. 24. This type of work requires specialist clinics with well studied patients, and clinicians with research facilities. In the UK there are only six such clinical services. The two substantially largest clinics see about 5,000 allergy patients each per year. 25. The role of allergy in asthma deaths. Deaths provide a clear end point. Unfortunately, the recording of asthma and allergy deaths has become compounded and asthma tends to be recorded to the exclusion of allergy (usually because of misdiagnosis) (Pumphrey 2004). Allergic asthma appears to be an important cause of sudden death, yet there has been virtually no study of this. New data is beginning to emerge from the Eastern Region confidential enquiry into asthma deaths—the first such enquiry with any allergy input—but there has been great diYculty obtaining funding for such work. This has important implications—for most of these deaths were in patients on standard asthma medication (ie apparently appropriate management), but the mistake was that allergy had not been considered. 26. Clinical guidelines are much needed. The lack of specialist clinical leadership in allergy in the UK (and very little NHS funding for allergy) makes clinical allergy research—and its translation to guidelines for practice etc—vestigial. It is not commensurate with the size of the problem and burden to the NHS. 20 million people have allergy at some time and about seven million need a specialist service (ie could not be expertly and safely diagnosed and managed in primary care). The direct cost for managing allergic problems has been estimated at £1 billion pa (Gupta et al 2004) but the reality is that much of the cost is invisible and incalculable because patients are undiagnosed. More capacity is needed. The essential first step is to increase the number of consultant allergists: there are only 26.5 wte consultants in the UK; and the limiting factor to expansion is the very small number of trainee places—only eight for the UK (not enough even to replace expected retirements—DH workforce data). This is a vital step, identified in previous allergy enquiries. 27. As research priorities are so closely linked to national clinical priorities, it is not easy to obtain research funding for a discipline with no priority. There is therefore a “double whammy”.
How effective have existing Government policy and advice been in addressing the rise in allergies?
28. On Policy For Service Development In Allergy Healthcare (i) The problem allergy presents to government is how to make a start to address a national problem with a devolved health service. (ii) The Royal College of Physicians gave unequivocal advice on how to do this three years ago: the first step is to get more specialists in allergy into the system. This would begin to create critical mass and improve the geographic distribution of allergy expertise. From these centres, support for other providers of allergy care and enhancement of services across primary and secondary care would flow. Normal processes could then take over. (iii) The House of Commons Select Health Committee (2004) endorsed the RCP Report and said that there should be an increase of 20 adult and 20 paediatric allergy training posts for doctors, and a commitment to create consultant posts for them to move into. (iv) The DH has implicitly rejected these recommendations as too centralist (2006). (v) The DH recognise the need to increase the specialist workforce in allergy but say this is a problem for Strategic Health Authorities and Deaneries to deal with. However the DH advice carries no requirement for action. (vi) The DH propose to leave the rest of service development to PCT commissioners. But it is known that PCTs lack the input and conditions to do this. (vii) Policy is needed to enable some action and move forward from this position. One way PCTs might be helped is by example, from a pilot scheme. What are needed are model services, which are working on the ground. These might be studied, used to train more specialists to seed out to new centres, work allergy: evidence 131
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with primary care and inform on the most eYcient way of developing services. DH might be asked to consider a national challenge fund for locally programmed developments, from which others can learn within the devolved NHS. This could provide an engine for major service development outside central priorities. 29. On specific policies—Government advice to tackle rise in allergies: little advice has been forthcoming. But there is a lack of evidence on what to do. For example, the DH advice on prevention of nut allergy (1998) was not evidence based, because of lack of evidence.
What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? 30. The first problem is inability to get an allergy diagnosis. This is widespread because of serious deficiencies in primary and secondary care allergy services. Education resources will have most impact once the correct diagnosis is made. 31. Some of the advice available direct to patients is of poor quality and highly misleading. Support for the work of the patient support groups, Anaphylaxis Campaign and Allergy UK, is required.
Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory? 32. Unorthodox and unsubstantiated practices including methods of diagnosis abound in the private sector (tests of no value are described in the RCP Report p 76–77). This is in part driven by absence of NHS allergy services. Many patients get the wrong diagnosis. This sometimes leads to medical harm; or financial problems for the patient; and wastes NHS funding—unproven private treatment is being paid for by some PCTs. 33. Even the established tests (specific IgE antibody)—without interpretation—can be misleading. Thus sales of these direct to the public eg supermarket, high street or through the media are harmful. Patients are diagnosed allergic when they are not and inappropriate management follows. Furthermore, there is a lack of quality control and tests in these laboratories can be positive when the same test in a CPA accredited laboratory is negative.
Documents and References [not printed]
Papers [not printed] October 2006
Examination of Witnesses Witnesses: Dr Mark Levy, University of Edinburgh Clinical Research Fellow and GP with special interest in respiratory disease and allergy, Royal College of General Practitioners, Dr Susan Leech, Allergy Representative, Royal College of Paediatrics and Child Health, Dr William Egner, Chair, Immunology Speciality Advisory Committee, Royal College of Pathologists, and Dr Pamela Ewan, Co-Chair, National Allergy Strategy Group, examined.
Q318 Chairman: Could I thank you for coming Committee will be introduced as we go through the today. Perhaps I could just remind you that this questions. Perhaps, Dr Ewan, you would like to session is webcast, so that it is out in the public start. domain. Members of the Committee have prepared Dr Ewan: I am Pamela Ewan. I am a consultant their interests on a paper available to the public, so allergist working in Cambridge, running a very large those declarations of interest will not occur during allergy service. I am also Co-Chair of the National this session. Any over and above will be recorded. Allergy Strategy Group, which is a group which has Perhaps it is worth just recording now that Viscount tried to drive forward the need for allergy services. Simon has encountered Dr Ewan in a professional Dr Egner: I am William Egner. I am a Consultant capacity,sothatwehavethatrecordedanddeclared. Immunologist working in SheYeld. I am also Chair Could I ask you at the beginning of this fifth public of the Standing Advisory Committee of the Royal hearing of our inquiry into allergy if you could College of Pathologists for Immunology and I am a introduce yourselves. I am Lady Finlay and I am practising immunologist who also provides an allergy chairing this inquiry and the other members of the service from my unit in SheYeld. 132 allergy: evidence
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan
Dr Leech: I am Susan Leech. I am a Paediatric Dr Leech: The College of Paediatrics and Child Allergy Consultant working at King’s College Health has a similar structure, both for supervising Hospital. I am the allergy representative on the and training, and there is an allergy curriculum which College Specialist Advisory Committee for Allergy, was developed based on the allergy curricula of the Immunology and Infectious Diseases of the Royal European Union of Medical Specialists who have a College of Paediatrics and Child Health and the curriculum for paediatric allergology. We have allergy representative of the British Paediatric developed an allergy training curriculum based on Allergy, Immunology and Infectious Diseases Group that with input from the adult allergy curriculum as of the same organisation. well. Paediatric allergy training for paediatricians Dr Levy: Good morning. I am a general practitioner comprises of two years of what we call “higher in Harrow. I have had a specialist interest in specialist training”—which is SPR training which all respiratory disease for nearly 30 years, including paediatricians do—followed by three years’ sub- allergy, asthma and chronic obstructive pulmonary speciality training in paediatric allergy. There is a disease. I edit the Primary Care Respiratory Journal, college specialist advisory committee which monitors which is a PubMed listed primary care journal. I am training centres and approves training centres. It also a part-time academic at Edinburgh University, I devises the curriculum and it also supervises training. am a clinical research fellow at Edinburgh, and Dr Levy: The Royal College of General Practitioners I am representing the Royal College of General has developed a curriculum and within the Practitioners at this Committee. respiratory extension of the curriculum it is probably fair to say that allergy is mentioned not in very much detail. I do not believe that the Royal College Q319 Chairman: Thank you. Perhaps I could start of General Practitioners oversees the quality of by asking you how the Royal Colleges work together training. The problem for GPs is really access to good to maintain standards in allergy training and quality training. developing the allergy curricula. Dr Ewan: The Royal College of Physicians, through the Joint Committee on Higher Medical Training, Q320 Chairman: Thank you. Is there a separate has devised an allergy curriculum which is a very curriculum anywhere—and it sounds from what you detailed curriculum, setting out what trainees should have said, Dr Levy, that there is not—for GPs who do. They have a log book in which the trainees record want to develop a special interest in allergy or for their experience during the duration of a five-year those people coming up through other specialties, training period. That is controlled by the college. The such as chest medicine, who want to develop a college also have a system in place where they can specialist interest in allergy? review training posts, both where there are centres Dr Levy: At the moment, it depends very much on suitable to have trainees and, also, once trainees are personal interest and personal drive, with GPs in post there is a system to review trainees as they go cobbling together diVerent courses and educational through. I think it is perhaps important to point out facilities that are available. For example, if a general that there are certain requirements for training, in practitioner wanted to learn about allergy or that you have to have appropriate consultants to specialise in allergy, they would have to do various provide the training—usually two consultants in the courses and then find clinical attachments, which are specialty—and you have to have an appropriate quite diYcult to find. They might get some theoretical clinical practice or experience for the trainees to training but the clinical part is very diYcult to access. provide the training required—mostly at the main Dr Ewan: Talking about the other medical centre but some trainees might rotate to other specialities, allergy is mentioned in their training centres. It is well regulated from the college point of curricula. It is mentioned in the respiratory medicine view. one, it is mentioned in the dermatology one, but it is Dr Egner: Yes, that is correct. The same committee really a very minor part of these and most people oversees the immunology and the allergy curricula. It training in those other specialties would go through receives input from both the SAC of the Royal their training with virtually little or no exposure to College of Pathology with regard to immunologists’ allergy. It is possible, of course, for people through views of how the curricula should develop, and the their own personal interest to gain more training. A Joint Committee for Immunology and Allergy, small number have indeed done that and have which is an intercollegiate Committee of the College become competent in allergy, but that is very much of Physicians and the College of Pathologists, which self-driven rather than available. I suppose the provides input and liaison between immunologists exception is respiratory medicine, in that, in allergy, and allergists and provides input into the JCHMT we do have a tradition of having been linked to and they balance the diVerent views there are respiratory medicine. However, this is centre-driven regarding the curriculum. rather than curriculum-driven and there are some allergy: evidence 133
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan centres of excellence. Most of the allergy major and perhaps have even come through respiratory centres have strong links and a strong background in medicine or other curricula training. With respiratory training. respiratory medicine in the past, there was a curriculum which allowed you to train jointly in Q321 Lord Taverne: You have told us what you are respiratory and allergy but that has now gone. doing separately but how far do you cooperate? Is Ironically, you can now no longer train jointly in there any overview by any one establishment? immunology and allergy, which one would have Dr Ewan: Not really, in that these committees thought was both logical and a way of introducing operate relatively independently. The diYculty is that flexibility into the system. All of these things are the integration might come at practice level rather introducing diYculties. than training level, I think, where one tries to network services. A major part of what is done Q324 Chairman: What is going to happen in the through allergy centres is networking with GPs in future to the person who then develops a specific their area and other consultants who have an interest interest as a clinician in an area with patients, who in their area, but this is not at the training curriculum has been trained, for example, only in immunology level, this is in practice. without being trained in allergy? Dr Egner: The immunologist’s view would be that the Q322 Lord Taverne: Is there any point in having immunology curriculum contains a large component more cooperation and some more coordinating of allergy. If one looks at European practice, there is eVort? Or does it not matter? Is all that matters that not a standard model. Some are joint training people should cooperate in practice? programmes, where you do immunology and allergy; Dr Ewan: I think it matters a lot that they cooperate others are stand-alone allergists; some have stand- in practice. That probably enables a larger number of alone immunologists; and a few countries lack one or people to become involved. But there is certainly a the other. We do not know what the best model is. It very major need in primary care for more training is now up to Trusts to appoint the people that they and for all GPs to receive some training in allergy. wish to appoint to perform a function. It is up to Currently GPs can go through their training with that individual and the Trust to be clear that that really no exposure to allergy. person is re-validatable, maintains professional development and is fit to practise in that speciality Q323 Lord Taverne: That is the worst gap, is it? and it is up to each individual doctor to know the Dr Ewan: It is a huge gap and it comes about because limits of their competence and to refer on. One of the there are very few consultant allergists in teaching major problems is there is no formalised structure, no hospitals, so it is possible to be a medical student and referral guidelines, no mechanism for referring on have one or two lectures on basic principles that and no access to the service because both might relate to allergy and that is it. No clinical immunology and allergy are rare breed specialities. exposure at all because there are no doctors to provide that training. Q325 Lord Rea: Dr Ewan, you mentioned the Dr Egner: I think it is important to clarify that the intercollegiate committee. How does that operate immunology and the allergy curricula are devised in coordinating the activities and curriculum and established by the same committee in development between diVerent colleges? collaboration, balancing the needs of the diVerent Dr Ewan: There is a joint committee, an immunology specialists about what each of those curricula should and allergy committee, which controls those two contain with regard to immunology components and curricula, with representatives of each speciality on allergy components. For those two curricula there is it, but, beyond that, the other committees are a balancing mechanism with regard to their content separate. One could perhaps have some input into but there is not, as far as I am aware, any interaction them but in reality they operate as distinct entities. between the Joint Committee on Higher Medical Training that oversees immunology and allergy Q326 Viscount Simon: My question overlaps the first and that which oversees respiratory training or question but goes a bit further than that, in that dermatology training and so on. Furthermore, we are paediatricians and other specialists, such as in a period of rapid change with regard to medical dermatologists, chest physicians and ENT surgeons, training and modernising medical careers, and the have to deal with allergic diseases within those fields. perhaps unintended adverse consequence of that is Is the training of these specialists in allergic diseases that you can no longer train jointly in a specialty. suYcient? You have to be on the specialist register for a single Dr Ewan: No, it is not. The reality is that they mostly specialty. The irony of that is that a lot of practising treat these diseases symptomatically without allergists in major allergy centres have strong links considering allergy. For example, asthma or eczema 134 allergy: evidence
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan can be adequately treated with medicines without who see patients with allergies. Part of the considering allergy. Diagnosing means identifying general paediatric training would cover things like the trigger for the disease and hopefully avoiding that respiratory medicine and gastroenterology and part or reducing it and so reducing disease episodes. In of that would include allergy, but they do not go into many children, eczema will be driven by food allergy. allergy in any great depth and as a consequence of If you can identify the food and avoid it, the eczema that there are fairly fundamental misunderstandings can disappear. The alternative approach which amongst paediatricians about allergy; for example, would be taken by a dermatologist would be to treat the use of the terminology is slightly incorrect it with creams or other drugs. For the most part these and can cause confusion. Therefore, even within other specialists lack allergy training and have their paediatricians there is a lack of proper understanding own approach to the disease. That is perfectly of what constitutes allergy. acceptable for a considerable chunk of patients with Dr Egner: This is perhaps reflected in the guidelines asthma and patients with eczema. From the allergy written by professional organisations regarding the point of view, we would not be arguing all these management of organ-specific diseases. If you look at diseases should be seen by an allergist—certainly guidelines, such as SIGN guidelines for management not—but there have been eVorts to calculate the of asthma or other respiratory diseases, the allergy percentage of those people with these diseases where component and how to select those patients who an allergy opinion is important. That still is a would benefit from additional investigation and how considerable number, although it is a minority of the to go about that is often not there. I think that this is total. That is where allergy comes in. Whilst it would one of the problems that may reflect this lack of be helpful to have some allergy training for awareness. dermatology and respiratory medicine, it is still going to be a small part of their whole remit. The other Q327 Lord Broers: Could you give us an overview of point to be made is that much of allergy is multi- the training courses that are available in allergy and system and another advantage of an allergist, tell us who attends them, please. assuming you need an allergy opinion, is that you Dr Ewan: Are you talking about training now outside sort out food allergy, drug allergy, asthma, eczema, of the allergy curriculum for specialists? rhinitis in a single consultation, so not only do you give the allergy diagnosis and management but Q328 Lord Broers: All courses. you also save sequential referrals and therefore you Dr Ewan: If we start at the top, there would be the reduce the burden on these other specialities, all of allergy specialist training, which is a five-year whom have their own waiting list problems. training. That is an excellent training but we have Dr Levy: This is further compounded by the problem very few people undertaking that because there is a from the general practice aspect, where the GP refers limited number of places funded nationally. Eight a patient with eczema to a dermatologist and does places only. not recognise that this patient may also have food allergy aggravating their asthma. That referral will Q329 Lord Broers: Eight places a year? result in a dermatological opinion, the patient comes Dr Ewan: Eight places in total, not a year. It takes five back to general practice and we need to re-refer the years to go through the programme, so every five patient on to another organ-based specialist. Where years these places become available. the general practitioner is not trained in allergy, they might not recognise the need for multiple opinions, Q330 Lord Broers: We produce 1.6 places per year! so the referral letter might not actually describe the Dr Ewan: That is the full specialist. Then we have problem very thoroughly. I agree with Dr Ewan 100 paediatric allergy specialists with their similar per cent that there is clearly a need for more allergy courses and then immunologists will do some specialists or more widespread training of the allergy in their training. We have talked about generalists in allergy. dermatologists and the respiratory physicians having Dr Leech: I would like to speak to that on behalf of virtually none. Apart from that, there are courses paediatrics. I think it has to do with the quality of the which people could undertake at the post-graduate consultation that is oVered to the patient. A general level. The biggest is run by Education for Health paediatrician who sees a patient with allergies will (which used to be called the National Respiratory usually manage the patient in a very superficial way; Training Centre). It puts on allergy courses. They are whereas in an allergy consultation you go a lot deeper primarily distance learning. They have a few sessions into the patient’s history and you address more than at the centre. They are theoretical, with a little bit of one of the patient’s problems. It is a qualitative practical when they go into the centre. They are diVerence rather than a quantitative diVerence. That mostly taken up by nurses, especially nurses from is not always appreciated by a lot of paediatricians primary care, but there are some nurses from the allergy: evidence 135
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan hospital sector. A small number of doctors go on increased knowledge in primary care. We find that these, mainly GPs, but it is very heavily nursing. areas where there are paediatric allergy centres or These are good value but they lack the clinical places where there are groups of people practising experience and so often these nurses want to have paediatric allergy can then develop local initiatives some sort of clinical attachment so they can put their to increase the knowledge of their local general theory into context and have a better understanding. paediatricians about allergy in general. I think the other diYculty is that these nurses then go Dr Egner: The two major issues are that there is back into primary care and they are isolated. They actually quite a lot of ad hoc training in allergy might try to start putting something into practice but, available through web-based modules, through drug because they have no doctor to communicate with or company sponsored roadshows, through college colleagues to communicate with, it is very hard for activities, through professional societies, but not a lot them to maintain what they have learned or really of it is practically based with regard to clinical properly put it into context. There are some other management. Much of it is theoretical and virtually courses around. There are some MSc courses. none of it is quality-assured in any way. The other issue is that immunology and allergy centres where Q331 Lord Broers: What is the impact of these people have an interest in allergy and a large service courses on the allergy services? Inadequate? will often provide local educational activities out Dr Ewan: Yes. It is better than nothing, clearly, to of their own initiative, but, again, there is no have them but we lack a suYcient network. GPs and standardisation of this. For example, in my centre I practice nurses can be very well maintained in an area lecture to local general practitioners, both by if you have specialist centres. If you have adult and invitation and through their GP training scheme. We paediatric allergy in a major centre, it is known that have taught nurses. We teach colleagues. All of these where these exist the GPs and practice nurses in the are very important activities but, again, they are penumbra can be better supported and can be fragmented. They are only available if someone enabled to do more. locally has the interest, because there is virtually never any time to do it routinely. It is all a question of making the time and seeing the need. There is no Q332 Lord Colwyn: I imagine there must be a terrific funding. delay between seeing a patient at the primary care level and seeing a specialist. Also, if there is a delay, surely the treatment might have already started, in Q333 Lord Taverne: In 2003 the Royal College of which case it is diYcult for a specialist to make an Physicians recommended that there should be informed diagnosis. clinical allergy training courses as part of the Dr Ewan: Yes. undergraduate medical curriculum. Has no progress Dr Levy: We published a survey of general been made on that at all? practitioners throughout the country and we sent Dr Egner: I do not have the data but I could guess that invitations to 500 GPs to respond, of whom 50 per very little has happened. We do know that the cent did. The delay in access to allergy consultations pathology component of undergraduate training has ranged from three to six months. The overall delay, if diminished over years and there is some data to show you looked at the extremes, was much longer. There that and immunology will be part of that. It has been were a few other points that came out of that survey, a concern that basic immunology (which obviously one of which was that about 50 per cent of these GPs underpins allergy), as well as autoimmunity, primary had had some sort of training in allergy. We do not immunodeficiency and other diseases which involve have much on the detail of what training they disease of the immune system is therefore not being received but more than 50 per cent of them felt that recognised because it is simply not being brought to their partners needed additional training. The their attention and does not form part of the thought worrying thing was that although they had not had processes of trainees because they have not really much training in aspects of allergy, like, for example, grasped or been taught the basic science. food allergy which could be life-threatening, they felt competent in dealing with these conditions. Q334 Lord Soulsby of SwaVham Prior: In view of the Dr Leech: We have two training centres for paediatric diYculties that you are all identifying, is there a case allergy. We recruit an average of one trainee a year: for videoconferencing? I know in dermatology in the one into one centre and then, the following year, one Royal Society of Medicine this was a very popular into the other centre, and it is a two-year programme form of postgraduate education. It seems to me that for them. There is an allergy MSc which is run out many of the problems in allergy lend themselves of Southampton which is very good, and a number of visually to a videoconference up and down the people go on that. I think what is needed are a lot of country and in fact elsewhere than within the United local initiatives to support this requirement for Kingdom. Has much attention been paid to this? 136 allergy: evidence
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Dr Egner: I do not think videoconferencing has been for GPs to undergo specialist training in allergy used in the same sort of way as it is used in radiology diagnosis and management? work, where people can sit around and look at Dr Levy: There is virtually none. If we look at central something; or perhaps in dermatology look at a rash drivers from the Department of Health or the Quality and have a case-based discussion about the and Outcomes Framework, it includes asthma, which diagnosis. There are web-based modules provided by could include an aspect of allergy, depending on the all sorts of providers, including the European expertise of the GP looking after the patient, but Academy of Allergology and Clinical Immunology invariably asthma management would not focus on and the American Academy and so on and so forth, allergy. Local incentives are driven by the primary which invariably do this by presenting either videos care organisations and based very much on savings at or still pictures together with additional information the moment. Allergy does not feature at all. A patient that people can evaluate. But they are of variable with cardiovascular disease or diabetes would get a quality. They operate in diVerent modules. There was lot of attention but not someone with allergy. As far an e-learning initiative by the Royal College of as I know, there was only one general practitioner Radiologists sponsored by the Department of with a special interest in allergy in the whole Health. I know the College of Pathologists is very country—and that was myself—employed by a keen to be involved in the next round of that, which primary care trust and that was for only nine months may well address some of the basic science and on an experimental basis. Despite demonstrating undergraduate issues, but we are unlikely to have the benefit for the patients and savings, allergy is not one resource to turn that into a clinical module in the way of the primary care trust priorities and the clinic V that you can get o some of the commercial websites closed down. that target medical practitioners.
Q338 Lord Soulsby of SwaVham Prior: Could the Q335 Lord Broers: Dr Ewan, do the eight candidates postgraduate medical centres with the postgraduate taking this full course have clinical attachments deans stimulate an interest amongst GPs? during that course? Dr Levy: Obviously GPs will try to provide the best Dr Ewan: Yes, it is almost exclusively clinical. They care for their patients, so if there is a talk or a lecture are in clinical practice all the time. Just to augment on allergy and they do not know much about it they the answer to the last point, all these courses are fine but there are two key problems. One is the lack of will attend, but the key driver at the moment is work specialists/lack of trainees to generate the future and availability of work. If you want to do general consultants. Another problem is doing something practitioner special interest work, a lot of GPs will fundamental in primary care—not just having focus on areas where there is work; that is, courses but including allergy as a key component of dermatology and cardiology. all GPs’ education. Dr Egner: I am sure there will be many general practitioners who would want to update. Adding an additional specialty to your practice provides Q336 Lord Taverne: My next question has been professional interest and clinical development. I have largely answered, which was whether GPs do receive two general practitioners who work for me. Just to any basic training in allergy. It seems that the answer illustrate that these posts are few and far between but is no. However, in so far as they do get training, who entirely dependent on local initiatives: they work as is likely to provide it and at what stage in their career? clinical assistants because I do not have access to any Dr Levy: There is some undergraduate training. formal programme for the development of GPs with The only evidence we know is from Edinburgh specialist interest—and nor does any allergist or University, where about 26 per cent of the 46 immunologist have access to that, although they are modules include an aspect of allergy, but it is the established in dermatology and rheumatology. One theoretical aspects and not focusing on diagnosis and of those has done the Southampton MSc course, as a investigation. Where the GPs get their training is result of which she had to undertake 18 hours, I determined by self-interest and self-drive. If you are think, of practical training in a clinic and that is how lucky enough, you can spend some time with a she came to me, and stayed, and has developed specialist in their clinic but most of the training is expertise in allergy. The other is probably about to do theoretically based, like the Education for Health that on one of the other courses and again is and the courses that Dr Ewan has mentioned. developing expertise. But there is no formal basis for this. They will not achieve a qualification for this, Q337 Lord Soulsby of SwaVham Prior: There is a there is no mechanism to give them one, but they will deficiency amongst general practitioners, I suspect, and have already gained specialist expertise which no from what you say, but what are the incentives doubt will be of use to the service in the future. allergy: evidence 137
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Q339 Lord Soulsby of SwaVham Prior: Is allergy, Earl of Selborne: I think we know the answer. as opposed to asthma, part of the Quality and Chairman: Yes, we have heard that loud and clear. Outcomes Framework for GPs? If it is not, should Thank you for confirming it to us. it be? Dr Levy: It should be. Those of us who made Q344 Lord Taverne: The picture we have is of proposals for the last Quality and Outcomes terrible mess. Is it right to say that this is probably the Framework did recommend that allergy was weakest aspect of medical training in this country? included. It was not accepted, unfortunately. Dr Ewan: Yes, I should think it is. You have to put it in context in relation to the clinical need. What is Q340 Lord Soulsby of SwaVham Prior: If we were to quite shocking about allergy is that we have this very make a recommendation— small service on the specialist side, we have virtually Dr Levy: That would be a key driver to stimulate GPs no knowledge in primary care, and yet we have a to know more about allergy. It would drive courses; huge patient burden. It is almost as if this has caught it would drive increase in quality of care; and I think up and the NHS has been caught on the hop and has it would generate a lot of savings in the Health not realised what is happening. There has, indeed, Service. It will reduce referrals and benefit patients been a big change in allergy in terms of patient need, and general practice generally. not only in numbers, which have increased very substantially, but also in severity and complexity. Q341 Lord Rea: Are there easily identifiable criteria There is this major need and patients are really being on which you could allocate the points that form part very poorly served by the Health Service. We are of the Quality and Outcomes Framework with regard back in the Middle Ages trying to think about it. We to allergy? Have these been worked out, as to how have had a series of inquiries about it, nothing much you would assess whether the doctor qualified for a happens, and unfortunately now the whole process has got caught up in the financial problems of the point if it were included in the Quality and Outcomes Y Framework? NHS and it is di cult to see local PCTs having any Dr Levy: There are various ways of addressing this. hope of sorting this out. One of the ways that we suggested was quality of Dr Leech: Allergy was not recognised as a sub- specialty by the College of Paediatrics and Child clinical care. For example, patients with asthma who V also have food allergy are at very great risk, the risk Health until 2000 and it a ects 20 per cent of the of dying, from allergic crises. GPs were asked to population. record the proportion of patients who had asthma and food allergy as being assessed. That could Q345 Countess of Mar: How often is it that your generate a useful indicator of quality of care. patients come to you and say, “I think I have an Unfortunately a lot of the Quality and Outcomes allergy and it is this”? Is it more frequent than the Framework points are derived by ticking boxes and training you get? there is very little evidence that quality care lies Dr Levy: Most of the time the patient gives guidance behind that. There is some research going on in to the GP on where the problem lies. We are taught Manchester at the moment which will hopefully at a very young age: If you want to know what is enlighten us. wrong with somebody, you listen very carefully to what they tell you. Q342 Lord Rea: Do you think it would be a help for allergy to be included in the Quality and Outcomes Q346 Lord Colwyn: I remember some of my Framework, even though the measurement of useful training—it was a long time ago now, in the sixties— activity in that field is diYcult to measure? and the allergy part of the training was related to Dr Levy: If diagnosis confirmed by investigations dealing with emergency procedures and reactions to was one of those criteria, you would need to provide drugs and various things, particularly as a dentist, evidence that investigations were done and that could that you inject into people or do to people. Would be a useful example of a good outcome. There are you consider that a part of the training? numerous steps that could be provided. The key thing Dr Levy: Anaphylaxis is certainly— is to get the word “allergy” into the Quality outcome Framework. Q347 Lord Colwyn: Not necessarily anaphylaxis but even less serious reactions. Q343 Earl of Selborne: Could you tell us what Dr Ewan: Yes, drug allergy is a very big part of strategies, if any, are in place to monitor allergy allergy now. It is mostly processed in the specialist training at the primary care level. centres. Unravelling drug allergy is very complex and Dr Levy: Unfortunately, none. diYcult and it is an increasing problem. 138 allergy: evidence
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Lord Colwyn: If you inject some local anaesthetic pure allergists as a specialty and paediatric allergists into a patient and they pass out, you have to know particularly. what to do about it. Q350 Baroness Perry of Southwark: What is the Q348 Baroness Perry of Southwark: I am turning to evidence that it is an attractive specialism? Do you the training of consultants now. Given that you have have diYculty attracting people into the course? If eight coming out every five years, how has the there were more training places provided, would it be number of allergy consultants changed overall in easy to recruit people? recent years? Dr Ewan: So far it has not been diYcult to recruit Dr Ewan: There has been an increase, although it is a people but we have had a small number of places. I small increase in a small total. In the last five years we think one of the diYculties is the small number of have had about five additional consultants, which is consultant posts and really what is needed is a not very much but there is some growth. Part of that planned, coordinated development, creating more has been by recruiting doctors from overseas and training posts but also with a promise of more some of it has been generated from our own trainees. consultant posts for them to move into. Equally, Another change which is perhaps beneficial is that, of there are problems. For example, I have funding for these recently appointed consultants, most have been an additional consultant post and I cannot see a NHS funded—which is a change. Of the existing suitable trainee to take it because there is nobody number—we have 34 consultants in allergy—a coming out at the moment. It is very diYcult to considerable proportion are academically funded. balance this when you have a small specialty. You are Whilst that is excellent in one way, in another it trying to argue the case for funding for a new post means the service may not continue beyond the life of and getting trainees to come through. One thing the head of department. Recently there was a big perhaps we should add to this discussion about the problem at Southampton when the Professor of numbers is that the way you get more people is Paediatric Allergy left and it was not sure if the having champions for the cause. You only get more service would fold. So far it has managed to limp money—because money is short everywhere—by along, and it may survive in fact. Having some NHS having somebody there who is pushing for the case, funding in the system is good. I think we have had and we have too few of these. So it is a slow growth. more growth in paediatric allergy than adult allergy. Dr Leech: We have eight consultants in paediatric Q351 Baroness Perry of Southwark: Are the allergy. Two of those were appointed prior to 2000. consultants spread widely across the country or do Six of those have been appointed post 2001. Of those you have a concentration in a few centres? six appointments, three of them are academic Dr Ewan: With the allergists, they are concentrated in appointments. Two that pre-dated 2000 are also a relatively small number of centres. There is not a academic appointments. geographical spread, so patients are therefore disadvantaged. Q349 Baroness Perry of Southwark: Are those Dr Leech: The paediatric allergists are concentrated figures UK wide or England? in four centres in Britain. Dr Leech: This is England. And we have had one paediatric allergist who has emigrated to Ireland. Q352 Lord May of Oxford: Do you think the NHS Dr Egner: Yes, I totally endorse the fact that, in terms monitors suYciently and thinks as carefully as it of appointments of allergists, whole time allergists ought to about the cost-eVectiveness of consultant- specifically, there has been a shameful lack of posts led allergy services against other forms of service created. We need to address that. We should not delivery? I also have a couple of follow-up questions forget, however, that immunologists do practice on alternatives. One is turning to services, as it were, allergy as a core part of their practice and there have out in the community and the other is turning to the been 23 of those appointed in the last 10 years—on a academic basis of understanding immunology. small base as well, because there is only a total of 61 Dr Ewan: No, I do not think they monitor what is according to the RCP census in 2005. Most of the going on. One of the problems is that the NHS trainees would look to practise allergy in some way, centrally has not had allergy on its radar until quite some as specialists, involving most of their clinical recently. They do not record properly what goes on activity, and others as a smaller part of their general with allergy in the NHS because it is a Cinderella activity. Knitting those into the picture of allergy subject, it is a new speciality. There is now an allergy service provision and getting a network that enables code, which was introduced into the NHS in 2005, appropriate referral pathways, care pathways and but that has only been implemented by the specialist guidance, is critical to making a better use of what we centres. They are now recording their work, and it have got, whilst also supporting the development of could be pulled out centrally by the Department of allergy: evidence 139
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Health as numbers of allergy patients seen, but, for Q354 Lord May of Oxford: It seems to me that this much of the rest of allergy, which is diVused through is much more broadly an area, like so many in other areas, there is no proper recoding of what goes medicine, where one is looking at the balance among on. The department does not have a good handle on the basic academic advances, the clinical application even what is happening in allergy. In terms of cost- of them and somehow the specialist things like eVectiveness, no, I do not think they have begun to be immunological training programmes to deal with it. able to address this. I am really struck in this inquiry more generally at the Dr Egner: I do not think there is any good data at the contrast between this and HIV (which is something I moment. I think it is going to be very diYcult to know quite a bit about). I can understand why there generate good data until we have standards of care, is such an emphasis on understanding the dynamics agreed referral guidelines and care pathways and an of the immune system and the interaction and what is eVective and equitable network of services which going on because of the magnitude of the global allow local access to people in a geographically problem, but, if you were actually to do some equitable distribution around the country. For weighted sum of the impact on health in the UK, you example, we have heard how the adult allergists and would probably find there ought to be more on the paediatric allergists are very much concentrated allergy, and yet, compared to the sophistication of in the South East, whereas the immunologists are the understanding at the molecular level and not at spread out over the North and South West and the pathogenesis of HIV that we have and the Wales. That all needs to knit together and we need to number of ace people working on it, I am struck by standardise care before we can look at the diVerent the rudimentary nature still in our understanding of models that are out there, before we can compare the immunological dynamics of much of allergies. Do them and know what is cost-eVective. The other thing you think this is just intellectual fashion? Do you is that many of us who are attempting to demonstrate think it is because there are things in other areas of leadership are trying new models of service. I am a immunology that lend themselves to more prestige or single-handed immunologist—I will not be for much more to the solution? Why is it that this is so much longer, thank goodness, but have been for the last five more rudimentary than other areas? Or am I wrong years—yet we have managed to develop services in my impression? Dr Ewan: I would have to disagree with you. We have using multidisciplinary teams, nurse specialists, excellent science and understanding of the basic clinical assistants, and those are all strategies that immunology and mechanisms of allergy but we need to be modelled and costed as a way of improving have— services for patients. Lord May of Oxford: Are there any community care programmes which monitor the patients that have Q355 Lord May of Oxford: It is still not generally been referred to specialist services, so that you get an agreed that peanut allergy comes from not being idea of what is going on in diVerent parts? exposed to it younger. That is a pretty fundamental question. Dr Ewan: Yes. We have very good basic science about Q353 Chairman: Dr Levy, did you want to say the mechanisms and understand the allergic process. something on the previous question? We lack, downstream of that, the clinical side. Dr Levy: The problem relates to diagnosis and then There are big gaps in clinical research. You have coding of the diagnosis. When general practitioners highlighted one very fundamental question. The refer the patients, most of them are using computer- other gap is clinical service. We do not have enough based systems and coding was one of the issues people who are looking at the clinical side, either communicated to this Committee by the College of research aspects or providing clinical service—and Child Practitioners’ report. If we refer patients into the two are interlinked—but we have international secondary care or, for example, a patient with allergic leaders in basic allergy research in this country. rhinitis to an ENT specialist, the code will be “ENT consultation” not “allergy consultation” so the Q356 Lord Taverne: I thought there was still a lot of information is not really there. contradictory evidence and uncertainty about the Dr Egner: We have forgotten how the Health Service causes of certain allergies. is funded—or I had—until this question came up of Dr Egner: The immunologist tends to have a finger in tariVs. We cannot generate a tariV until you have many pies but we are supposed to have mastery of the some reasonable model of care and care pathways basic science of the immunological components of that are roughly similar throughout the country; lots of diseases, from autoimmunity, through to otherwise you are going to end up with a cost in one allergy, through to primary immunodeficiency. centre that does not reflect the cost of the service in There have been massive advances in the another and that will cause all sorts of problems. understanding of allergy but, without wishing to 140 allergy: evidence
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan understate the point, it is not quite as simple as some Lord May of Oxford: There is a discussion this of the other single gene defects that we have been able evening at the Royal Society which you probably to isolate to understand the immunology of, for know of. example, primary immunodeficiency. We can isolate Chairman: I wonder too whether there has been a a single pathway and the consequences of disruption huge drive through general public pressure. Whereas of that pathway, following, particularly, through diseases such as cancer and HIV are seen to be life- individuals who inherit it in an X-linked form, so that threatening primarily, diseases related to allergy are males in the family are involved. Those are all areas viewed much more in the public eye as being some of the immune system in which we can gain a fairly kind of inconvenience rather than life-threatening rapid understanding of the key pathogenesis of that and therefore they have taken a low priority in the disease. Allergy is diVerent. One, not only is it multi- political pressure for research funding to go into system, the susceptibility is related to both genetics those areas. and environment and the complex interplay of those, and that is much more diYcult to unravel. The other Q359 Lord May of Oxford: There is this concept of problem, as Dr Ewan points out, is that we do not the disability-adjusted life years which is more and have the network of services working in a more used as a measure of medical impact rather than standardised way in order to enable us to do the just looking at mortality. Has anybody looked into applied and translational research and service the impact of allergies by that kind of measure that is delivery research and cost-eVectiveness research that more conventionally used in the developing world, in we ought to be able to do very well in this country but terms of the disability-adjusted life year impact we do not have the resources. compared to just asking mortality? Dr Leech: I have one slightly cynical comment. I Dr Egner: I am not sure about disability-adjusted but would ask how much of that HIV research is driven various other measures of quality of life indexes and by pharmaceutical funding. so on have been used for allergic rhinitis, showing that it may not kill you but it can make a lot of people Q357 Lord May of Oxford: I would like to amplify miserable and therefore is a considerable health what I said earlier, in the sense that I think your burden. This applies to various other allergic answer to me said that it is a mixture of the fashion diseases. And of course the fear of thinking you might at the academic end, in wanting to do clean questions die if you were to accidentally ingest a bit of peanut rather than messy questions, as distinct from is awful. That is a major component of giving advice; important. My impression would be that the trying to give people ways of coping with this and community of academic/clinical people working on trying to reassure them, as far as we can, that they HIV internationally would be three orders of have appropriate treatment is a very important magnitude more than in allergy research. That seems function. to me out of whack. I personally think it is fashion, Dr Levy: There is also good evidence that rhinitis can in a sense, but understandable fashion. aVect children’s performance in school. That aspect Dr Leech: I think a lot of allergy research is of quality of life has been investigated quite around the basic science research but then the areas thoroughly. of uncertainty are around causes of allergies, particularly early life events and allergen exposure. I Q360 Chairman: How much have things like the think the teams that are working on those research dermatology life-quality index been picked up in areas find it very diYcult to find funding for those general practice research in relation to eczema? types of research projects. Dr Levy: It is not on the Quality and Outcomes Framework so it is unlikely to be picked up as Q358 Lord May of Oxford: And not just for routine data. pharmaceutical things, it seems, but in the medical research category, it is the same people who like the Q361 Countess of Mar: I recall about 15 or 20 years neat questions rather than messy questions. ago there was a rush of papers which put a stigma on Dr Egner: In many ways the recent Cooksey report on allergy, saying that it was “all in the mind”. Are you the future of funding of research in the NHS suVering from the tailback of that in relation to these addressed this question. It basically said that applied multi-symptomatic, multi-system diseases? research was under-funded. You are only as good as Dr Leech: Yes. I think that has been a big problem in your last research grant and the outcome of that. In Britain. If you compare the development of allergy a competitive research environment, it is a brave services in Britain with those in Europe and the person who goes into a messy area with no United States, Britain has been in the backwater for clear outcome because they have to justify their the last 20 years, possibly as a result of papers you subsequent academic funding. have described. In Europe and in the United States, allergy: evidence 141
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan allergy has continued to grow and we feel we are just extremely disappointing and speaking on behalf of starting to catch up with what has been happening the Royal College of Physicians, they are extremely elsewhere in the world. disappointed with the outcome. Dr Egner: The College of Pathologists are also Q362 Lord Rea: In 2004 the House of Commons disappointed with the outcome. If there were any Health Select Committee produced a report and positives that came out of the review, I suppose recommendations on allergy training posts and the at least the intention to consider options for specialist allergy workforce to which there was a commissioning NICE guidelines is some form of Government/Department of Health response. Are progress and to work with the Royal Colleges on the Royal Colleges satisfied with that response? development of guidelines and referral and care Dr Ewan: No, they are not, they are extremely pathways is a potentially positive development. It is dissatisfied. The Department of Health’s initial good to see that the review recognised the multi- response to the Commons Committee was that on disciplinary contribution to allergy services and a lot most of the key questions they evaded a direct of good work and leadership that is already going on response and said they would hold their own review. out there. What it did not do was give us any tools or Those key recommendations from the Commons any drivers which would help local champions, or Select Committee were to increase allergy trainees individuals who were interested in setting up and and to increase allergy consultants and to improve running networks, or putting in place a governance training in primary care. When the Department of structure and standardisation of care to work with Health eventually did hold their review, which was a and that was very disappointing. They left it to local year-long review, at the end of it they produced a commissioning, so deaneries were to decide whether report which still did not address the Commons’ or not they needed trainees in allergy—“to consider recommendations so they really remain unanswered. the options” I think was the wording—and I think they completely evaded the main points. One commissioners were to consider whether allergy of the diYculties is that at least the Department of services were needed, but yet the whole thrust of the Health in their review recognised and agreed with the report was that allergy services are needed and are problem, so they have accepted that there is a dreadfully under-resourced and they are inequitably problem and the size of the problem and that there is distributed around the country and the training a need to do something but they have not really network could be better, so I am afraid overall a very addressed how one would go about solving it. They disappointing outcome. suggested in their report that this should be up to Dr Leech: The Royal College of Paediatrics and Child primary care trusts and to strategic health authorities Health has similar problems. One of the additional so they have failed to take on any central problems is that there are so few paediatric allergy responsibility for putting any pressure to actually specialists and there are huge areas of the country bring about change. I think the diYculty now is where there is nobody to champion paediatric allergy primary care trusts have huge financial problems and services and those issues are therefore just not dealt so they have two roles really, firstly, to serve the with. health needs of their populations and, secondly, to balance their books and these two roles are Q364 Chairman: We heard from the Department of incompatible and at the moment balancing their Health that their plans are that a lot will be devolved books is the priority, so to expect primary care trusts out to general practitioners. Who is going to do the to be able to do anything for a new speciality or education of those GPs? a growing speciality just will not happen; it is Dr Leech: That is the problem, there are not the unrealistic. people to do that. Dr Levy: Without coding systems which identify the Q363 Lord Rea: Are there any possible plans for actual burden of allergy, GPs will not be aware of the maybe when this crisis is over—if it ever is—to need for training. encourage or endorse the creation of additional Dr Egner: I think we need to understand the context consultant posts for trainees to move into? here. If all future developments are going to rely on Dr Ewan: I think the first problem is that we need persuading local commissioners and PCTs that they more trainee posts and we need more funding for require local services, you have to be able to justify them. There is no way the primary care trusts would your existence by producing some data to show that be prepared to fund these at the moment. Although you are a fit-for-purpose service that can meet we are getting a few more consultant posts that is not national standards, but we do not have those primarily coming from PCT initiative; it is coming national standards yet. You have to demonstrate that from the driver of local champions who have been you provide value for money. You have to compete pushing the service. I think the whole thing is with 57 other medical specialities who are all 142 allergy: evidence
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan producing cases that their services are under- little since, and they calculated the ideal need, which resourced and you are doing this on the basis that you of course no-one was expecting or asking for, would have a specialist workforce which is tiny and already be 520 consultants. This is combining adult and over-stretched and the reality is that is going to make paediatric allergy, so that puts it into context. It life very diYcult. It is incumbent on us to try and do seems a ridiculously large number so asking for 20 it, but it took a very long time for immunology to and 20 was a start-up but it was thought important establish itself as a specialty and this is going to set because that would begin to turn around the service. allergy back quite some time. Even if it just doubled in size and one had this geographical spread it would be a very important Q365 Lord Colwyn: I think your evidence today and focus to network with immunologists, to network in fact all the evidence we have heard since this with primary care and to grow the service. inquiry started, has made it quite clear that the paediatric and adult specialist workforce is totally Q367 Lord Colwyn: Is there a nationally agreed inadequate. You mentioned earlier that there had definition of “complex allergic disorder”? been an increase of five consultant posts and six in Dr Ewan: It is all set out in this paper in detail. paediatrics. Can you make any recommendation Dr Levy: I wanted to just add that while I agree we do about how many consultant posts there should be in need more specialists, it would be impossible for all of the ideal world to deal with this increasing problem? the patients with allergies to be treated by specialists, Dr Leech: The figure that was quoted in Allergy: The and while we are increasing the specialist contingency Unmet Need was 20 paediatric allergy consultants we need to focus quite a lot on primary care expertise. and 20 adult allergy consultants, and that was to For example, access to tests and investigation. Very provide one in each region of the country. I think that few primary care practices provide allergy testing. It will probably just be a start. I think you would also is less than four per cent in fact who do skin-prick need allergy consultants in each hospital. testing and access to specialised blood tests is variable throughout the country. In some areas we can get Q366 Lord Colwyn: Our briefing from the Royal access to IgE tests but in most areas we cannot get College of Physicians talks about one in 3,500 access to specific IgE tests because of the cost. members of the public having some anaphylactic Dr Egner: I think the consultant workforce and the reaction and drug allergy responses are responsible GP workforce and the training issues and manpower for five per cent of hospital admissions. What are the issues related to those are all critical and key in terms estimates of the number of patients who have multi- of underpinning the structure but if there is such a big system allergic disease or allergic problems? need we need to think creatively about how we can V Dr Ewan: This has been worked out very carefully deliver these services e ectively and nearer to the and was produced in a paper by the British Society patient, which is the direction in which the Health for Allergy and Clinical Immunology and submitted Service is going. We should not forget nurse to the Department of Health review and a lot of work specialists, we should not forget GP clinics or GP went into trying to calculate this. They tried to come with specialist interests and other mechanisms for up with some fairly conservative numbers because delivering care closer to the patient, all of which we there is missing data over quite a number of these do not have models for at the moment nor any V areas, but at a conservative estimate it was felt that evidence for cost-e ectiveness. I think all of these about seven million patients had severe or complex or things need to be considered in the round. multi-system disease which warranted referral to a specialist. This still leaves an enormous number, Q368 Viscount Simon: Having heard how close many millions, a much larger number for primary immunology is to allergy, would there be any care. There is no way that the sort of diseases in this advantages in combining the Certificate of seven million could be dealt with in primary care. Completion of Training in Immunology with that There is not the time, the competence, it would be for Allergy? risky, there are more complex procedures required, Dr Egner: I think that has been tried in the past and so there is a huge burden. As Dr Leech has said, was not successful. It is a model that applies in other the Royal College of Physicians recommended this countries but I think we need a UK solution that best start-up of 20 extra adult and 20 extra paediatric fits UK needs. I personally am in favour of it, others consultants which was simply to try and get a centre are completely opposed to it, and there are arguments in every area of the country so one had at least a focus and pros and cons on both sides. My worry about the to develop the services locally. At the same time the future direction of consultant staYng in the NHS is Royal College of Physicians Workforce Department that we need to retain flexibility. It is a core concept calculated the true need and this was done in 2003 on in the new medical world that people’s competences the data at that time, which has probably increased a need to be configured for local needs and in many allergy: evidence 143
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan ways, prior to Modernising Medical Careers and the small specialities, which is why in many ways the new CCT, people were relatively flexible in the situation with immunology and allergy and other competences that they acquired before qualifying as specialists with a small workforce actually requires a consultant and going on to the specialist register or more nurturing and support from government policy whatever preceded that. Now we are much less and more drivers. Losing a few haematologists would flexible I think that is to our disadvantage and may be cause major problems as they are already to our disadvantage with regard to recruitment. The understaVed but it would not cause the whole other issue of course is that it is not all about the CCT service’s future to be in doubt, which could very any more. The CCT is where you start and the easily happen with either of these specialties, and I Academy of Royal Medical Colleges has considered think they both need to be valued and to be nurtured. whether perhaps CCT credentialing—adding on whistles and bells and other competencies—is a way in which that flexibility can be delivered, and Q370 Chairman: Given the shortages that you have all of that remains in the round. It may be that described and the uneven distribution of services, a respiratory physician can add on another how do you see the resource of the immunologists, competency specifically related to management of which seem to be a resource better spread allergic disease and so on and so forth. We do not geographically, certainly across the UK, being really know where we are going yet. harnessed to meet clinical needs? How do you think Dr Ewan: Coming back to Viscount Simon’s that the shortage that you have outlined could be question, one of the disadvantages of combining addressed in the short term by more collaborative those two CCTs is that immunologists have many working between the two groups in adult and also, roles other than allergy. Allergy is one thing they do possibly, with paediatric allergy as well? but they have an important role in providing a Dr Egner: I think the paediatricians are an exemplar in this in that they work together completely; diagnostic laboratory service and looking after V patients with immunodeficiency—some of them look paediatric training is organised in a di erent way after rheumatological problems or vasculitis—so from adult training. We do already. The idea that we they have a wide remit and allergy is part of that, in do not, I think, is incorrect. We have a joint some cases a small part and for other immunologists committee of immunology and allergy; we have the a larger part depending on personal interest, whereas BSACI, we have the new immunology society under allergy is focused 100 per cent on allergy. In terms of the aegis of the BSI, all of which have an interest in need, the need is the allergy patient, so if you come at promoting and developing the standardisation of it from the patient perspective, it is less eYcient to services, networking and promotion of clinical train people up to do a lot of other things where there guidelines. The Department of Health has made a is not an increased need whereas the allergy need statement saying that it is keen to facilitate that, and is the important aspect. So that would be a the Royal Colleges will have an interest in that. All of disadvantage of combining the training because you this can do nothing but strengthen our hand by would have to spend all these years doing training allowing us to provide the evidence which the that immunologists do which allergists do not require Department of Health review indicated was not to do. there, in terms of what are the best models for service delivery, what is the most cost-eVective way of service delivery and how can we improve training and Q369 Lord Colwyn: Do allergists get on well with education. In many ways, of course, it is back to us, is immunologists? it not, to try and lead this? Immunologists and others Dr Egner: On a personal level, yes. It is quite normal, work together very well in doing this. Some centres in fact it would probably be abnormal, if we did not have both; some centres only have one—who knows have diVerent views on how services should be what the right model is. It may be diVerent in constructed and in fact even on the allergy content of diVerent places. the curricula. What is important is whether patients Dr Leech: The story for paediatrics is completely are going to get the service they deserve? Specialist diVerent. When you train as a paediatric allergist allergists are going to be extremely important and a your fundamental training is within paediatrics—it is key provider of allergy services, so how can we the same for immunology and it is the same for a support them because they are in the situation that paediatric infectious diseases consultant. The CCST immunologists were in the 1970s. They have a very that you get following completion of training is small (almost no) critical mass of specialists and paediatrics, and then in brackets there is a minor changes to training, to recruitment and to the recognition of your sub-speciality training. There are availability of jobs (which we need to look at as well not separate sub-specialities for allergy, immunology because there is no point training people if no-one and infectious diseases, so the sub-speciality you are will employ them) can have disastrous eVects on awarded at the end of your, for example, mainly 144 allergy: evidence
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan allergy training, is a CCST in paediatrics, (allergy, Dr Egner: Immunology shares most of those features. immunology and infectious diseases). Paediatric Trainees are encouraged to do research because the immunologists focus on treating children with very skills and the critical thinking skills which are complex genetic defects in the development of the generated by participating in peer-reviewed research, immune system; they treat patients with bone either within programme or out of programme, doing marrow transplants; they are very focused on that an MSc or a PhD or a DPhil, is regarded as being kind of work, and that is focused within two centres useful in what are, basically, cutting-edge specialities in Britain. They are really not interested in with complex science that require you to keep abreast developing big allergy services. Most of the of the literature and to somehow translate that, development of paediatric allergy service is left to the eventually, into something which can be used in the paediatric allergy people that are based within the clinic. That is equally true for paediatric and adult south of England. allergy and adult immunology, but it is not Dr Ewan: What I think is important to emphasise is mandatory; you do not have to. As Dr Ewan alluded we need increased capacity, and that can come about to before, the good news, but also the bad news, is in multiple ways. All service contributors are needed, that most new posts are being based on service and are useful. However, unless you increase the commitment. They are NHS posts, and what PCTs capacity from the point of view of the allergy patient are interested in is how many patients can be seen and there is a big problem. So whether it comes from given appropriate care and advice most eVectively. immunology or paediatrics or allergists or other Finding time for research and development within specialists, that is the important point. The way you those heavy and increasing commitments is an Y will most e ciently increase capacity is to train more increasing diYculty for both trainees and existing people who will spend 100 per cent of their time doing consultants, as historically that has always been an allergy, but all these other ways of working will important role of immunologists and now it is to interlink. Importantly, from the patient point of generate new applied research. Most of them are view, if the driver in the NHS is to keep as much in based in academic centres, but there is a separate primary care, what is going to be coming up to pathway now for people who wish to specialise in hospitals will be the more complicated and diYcult academic careers, who are expected to slot into this at patient. So not only do you need capacity but you a very early stage in their career before they have need comprehensive expertise to provide that. taken any other training. There are worries about Another important aspect of emphasising the value how that will aVect our ability to deliver research and of centres is the huge education role that needs to development, and the future role of the specialities in take place across the board of all health care that, but we do not know how that is going to pan professionals. out. I should point out that the research someone Dr Leech: One thing we have not talked about yet is that, in the way we talked about increasing the chooses to do depends on local opportunities and knowledge of general practitioners around allergy, interest. For example, at least two of the immunology there is also a need for developing the knowledge of trainees in post at the moment are doing PhDs and general paediatricians elsewhere in the country to DPhils in allergic conditions or immunotherapy. I do help manage this load of paediatric allergy patients. not know about the allergy trainees. Dr Levy: We have had a number of questions related to evaluating quality of care, and in primary care Q371 Baroness Perry of Southwark: Is allergy while research training is not essential as part of research a necessary part of allergy clinical training, clinical training it would certainly help if it was and is it currently included in the curriculum? incorporated within primary care training, both to Dr Ewan: It is a part, yes. Of the five-year training, understand the literature that is coming out and, also, one year is devoted to research, and it is an important politically, to defend oneself against the claims of part because it provides an important understanding ‘evidence-based’ decisions by managers. A lot of of research and enables people to be able to our services are determined by primary care independently conduct research in the future. It is organisations, and very much on the basis of also a very important part of learning, but there is a evidence, which the managers have interpreted, and I one-year component, which might be clinical or more think it would be helpful to be able to have a clearer basic research in the training curriculum. understanding in general practice. Dr Leech: The way it works in paediatrics is that, again, we have got one year which is accredited for research but the trainee can do a research programme Q372 Baroness Perry of Southwark: I was going to that lasts three years, but one year of that would ask a supplementary, but it might chime with what be accredited towards their five-year training you were going to say. I just wondered if the Walport programme. process, with the additional fellowships and the 11 allergy: evidence 145
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan new training posts, is going to make a substantial diVerences, but there are a number of countries in diVerence. Europe where allergy is a full speciality, and the Dr Egner: It might if we bid, but I have not been curriculum is somewhat like ours. The numbers of involved. posts are hugely diVerent. It is quite diYcult to get Dr Ewan: It would depend on whether any of them exact numbers from many of these countries, and it is were allocated to allergy. easier to get numbers of consultants, or to have an idea of consultants, than trainees but one is talking Q373 Chairman: We had heard from Professor Sally about hundreds or, in some cases, thousands in some Davies when she gave evidence to us that there were European countries, whereas we have eight trainees 11 being allocated specifically to allergy. That was in and 34 consultants here in immunology. So there is a our first evidence session. huge diVerence in numbers, and we are very much a Dr Egner: It is good news we are not aware of!8 poor relation. Dr Leech: 9 Dr Leech: I can give you the figures for consultant paediatric allergists. At the time it was estimated, in about 2003–04, there were five British UK allergists, Q374 Lord May of Oxford: How do the curriculum and in France, Sweden and Switzerland there were for allergy training and the number of allergy 20. training posts in the UK compare with other OECD countries, like the US or Australia and, most particularly, with other countries in Europe? Q375 Lord Colwyn: In each? Dr Ewan: I am a representative for Allergy in Europe, Dr Leech: Each. and the Union of European Medical Specialities has Dr Egner: Just to emphasise their heterogeneity; in a an allergy section, and they have recently developed EUMS survey of 23 European countries, which I an allergy curriculum for Europe, trying to bring think was presented at the European Congress of together the various countries in the EU. The Immunology in 2006, there were 16 European curriculum is quite similar to the UK curriculum and countries with training programmes in immunology, they partly used the UK curriculum when developing five of whom were conjoint with allergy and include the European curriculum. There have had to be some allergy within that training programme; seven had variations in terms of duration of training, because stand-alone allergy programmes and six had stand- there are a lot of diVerences between individual alone laboratory immunology programmes (which countries as to how they practice. In some countries would not be a runner in this country). In Australasia of Europe allergy is a full speciality and in others it they have two programmes, a three-year training is a sub-speciality. For example, in Germany it programme, which eVectively produces a physician is heavily linked to dermatology, so there are immunologist and allergist who can see patients with any spectrum of immunological or allergic disease, 8 With regard to the additional allergy posts under the Walport scheme announced by Professor Davies—this is potentially good and a four-year programme which includes news but requires clarification before it can be assumed that it laboratory training which also qualifies that will aVect service provision and consequent applied research in individual to supervise the laboratory, which is allergy for the benefit of patients. (a) At what level are these posts—Are they Academic Clinical core to, certainly, the UK immunology training Fellowships, Clinical Lectureships of “new blood” Senior programme, because that is a core competency. lectureships, Academic GP fellowships of GP one year post-doctoral fellowships? (b) Where are they based—Much allergy research into asthma Q376 Lord May of Oxford: Is that actually co- is performed by respiratory physicians and into allergic skin ordinated in Australia and New Zealand? disease by dermatologists—are they in existing allergy centres with links to a specialist allergy or immunology Dr Egner: Yes, it is. It covers both and it is a model I service? particularly like. (c) Are any of the appointees undertaking training as Allergists or Immunologists or are they pursuing other speciality training programmes? In other words what will their CCT Q377 Lord May of Oxford: How about the US? Is speciality be? that too varied to be able to give an answer? I do (d) What is the scope and type of the research programmes that will be supported by these posts?—Are they supporting realise the written thing you were given just said research into allergic diseases which are currently less “Europe” and I am not quite sure why. favoured in the UK such as rhinoconjunctivitis and food allergy? Are they supporting basic science, applied science Dr Egner: There are laboratory immunologists who or service delivery? do have little in the way of clinical practice in the 9 We are delighted to hear about the 11 clinical academic training USA, and most of their physician practice is programmes in allergy. We would, however, like to point out that there will be a minimum of eight years from commencing a clinical dedicated to serving allergy. fellowship to gaining a CST and being eligible for a consultant of Dr Ewan: I do not know the numbers in the States but senior lecturer post. they are very large. However, allergy in the States will We feel it is imperative that the needs of children are considered in addition and an equivalent number of academic training posts be either in hospitals and often linked to academic should be allocated for training in paediatric allergy. centres, and then there is a huge amount of private 146 allergy: evidence
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan practice. I do not know the numbers, but it is management of certain disorders and this is a enormous. relatively new initiative that has only been going for Dr Levy: There are probably a lot of hidden allergists the last three years, so that is in progress, but there in Europe. For example, in Germany a lot of primary are GA2LEN guidelines which are quite helpful care doctors are trained in allergy and they would not within education. be counted amongst the consultants. Certainly in Dr Egner: A very important initiative, although Scandinavia a lot of general practitioners provide whether it will have practical implications for the allergy services. It is an area where we do need more practice and management of allergy patients in the information. Can I just ask, if it is not too big an UK remains to be seen because in the UK-based imposition, if maybe some follow-up note could be guidelines, practice diVers—and not only within the sent about that. It would be really helpful. UK, but within Europe and America—so there are Chairman: Yes, it would be helpful and it would help many guidelines which are freely available from the us understand the details which would fit with Lord American Academy of Clinical Allergy, Asthma and Taverne’s request as well. Clinical Immunology, but they cannot be directly translated into service-based guidelines here. There Q378 Earl of Selborne: I wanted to ask about the are lots of local initiatives that we need to network Global Asthma and Allergy European Network and share. For example, locally we organise our which oVers training and educational activities. Do allergy practice using standardised guidelines, we take full advantage of these activities and do we protocols and care pathways which are modelled on adopt the standards and resource utilisation signalled those immunologists use in immunodeficiency. There by the Network? is a national network of all UK PIN clinics and you Dr Leech: I spoke to John Warner yesterday who has are required, in order to be accredited, to have a a large part in GA2LEN within paediatrics. Their quality manual, a quality statement, document- educational activities are that there is a sort of spring controlled guidelines which cover your nursing, your school in Davos for postdocs and doctoral scientists doctor-led activities, your dietician activities and care and then there is a summer school which is a clinical pathways for individual patients, and I think that is allergy school which they hold once a year. His a very useful model and some centres are already response was really that they are preaching to the sharing this. For example, we are doing that within converted. These are people who are already Trent to see if we can standardise care within the interested in allergy and already committed to a immunology and hopefully the allergy centres there. significant part of their allergy service which, when I think sharing good practice is something we could you go on these courses, you can get knowledge from. do a lot better and we could do much to facilitate It does not really filter down to the grassroots which networking. I think the GA2LEN guidelines and is what I think we have identified as being needed international guidelines may inform this, but they here. will not replace them.
Q379 Earl of Selborne: Do you know whether any allergy treatment centre in the United Kingdom has Q380 Chairman: I just wondered, to wind up, if I ever been certified by this Network either at certificate level one or two? could ask each of you if you in turn could identify Dr Ewan: No, they have not yet. This is a very what you think is the single most important issue to recently introduced scheme. There are three centres address to drive up, and improve, allergy education in the UK which might be possible to be accredited at and thereby also help the service needs. level two which is Guy’s and King’s, and the Dr Ewan: I would like to see more funded training Brompton and Cambridge might be possible centres, posts in allergy. but no one has yet made an application. It seems a Dr Egner: I would like to see that, but first I would very complex and quite bureaucratic process just like to see standards, a network, and models of care submitting the application, but these centres are in place as well. considering this at the moment. Another thing Dr Leech: I would like to see many ways of increasing perhaps to mention in relation to GA2LEN is that allergy awareness for the people who are responsible they do produce guidelines on management of for delivering care to the patients who are, in allergy, so they have a number of educational our service, general paediatricians and general initiatives in addition to their training courses. Of practitioners as well. I think that needs a bottom-up course we do in the UK have guidelines on allergy, and a top-down approach. but we are perhaps behind Europe in the number we Dr Levy: I think including allergy or aspects of produce, but the British Society of Allergy and allergy in a quality outcomes framework would be Clinical Immunology produce guidelines on the key. allergy: evidence 147
17 January 2007 Dr Mark Levy, Dr Susan Leech, Dr William Egner and Dr Pamela Ewan
Chairman: Thank you very much. Could I thank you correct for accuracy in case anything has been taken all for coming for this session and for having helped down inaccurately. I believe, Dr Ewan, we will have us explore these diYcult issues. If there are things the pleasure of coming to see your unit, so there may which come to mind when you leave here, please do be other aspects which you would like to share with submit them in writing to us and they will supplement us then. May I finish by thanking you very much the evidence we have had from you today. You will indeed for being here today. be sent a copy of the transcript for you to look at and 148 allergy: evidence
WEDNESDAY 31 JANUARY 2007
Present Broers, L Platt of Writtle, B Colwyn, L Rea, L Finlay of Llandaff, B Selborne, E (Chairman) Simon, V Perry of Southwark, B Taverne, L
Memorandum submitted by the Food Standards Agency
Introduction
The Role of the Food Standards Agency
Responses to questions posed by the Committee that are relevant to the work of the Food Standards Agency
Defining the problem What is allergy? What is the diVerence between allergy and intolerance? What is and what is not known about the origins and progression of allergic disease? Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such a high prevalence of allergy?
Treatment and management Is the level of UK research into allergy and allergic disease adequate? What are the most promising areas of research into preventing or treating allergy?
Government policies How eVectively are food policy and food labelling regulations responding to the rise in food allergies?
Patient and consumer issues What impact do allergies have on the quality of life of those experiencing allergic disease and their families? What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed suVerers? Are current regulatory arrangements, for example, those governing private clinics oVering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory?
Introduction
The role of the Food Standards Agency The statutory objective of the Food Standards Agency (the Agency) is to protect the health of the public and the other interests of consumers in relation to food and drink10. The Agency was set up in April 2000 as a separate Government department, at arm’s length from the political process (although accountable to the Westminster Parliament and to devolved equivalents through Health Ministers) and with a clear objective. The independence of the Agency is given eVect both by its formal status as a non-Ministerial UK Government Department, led by a Board appointed by UK Ministers to act in the public interest and by its powers to publish the information and advice that it issues, including advice to Ministers. 10 Section 1(2), Food Standards Act 1999. allergy: evidence 149
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Our role in relation to food allergy and intolerance is to develop policies that allow consumers to make informed choices about their diet. We do this by negotiating and implementing legislation to improve statutory control on labelling of food allergens, and also by providing best practice guidance for industry and enforcement bodies to encourage greater awareness and control of food allergens through the food supply chain. We also provide advice about food allergy and intolerance for consumers so that they understand and can use the information provided to them by food businesses. We do this via our website and through published materials to help consumers make informed food choices that will ensure their safety, whilst not unduly restricting the choices available to them. We also commission scientific and consumer research on food allergy and intolerance to ensure that policies are based on robust evidence. Food labelling is an area of EU competence and therefore national legislation in this area implements the relevant EU legislation. We negotiate on behalf of the UK to ensure that EU legislation in this area addresses the needs of UK consumers and industry. However we also produce best practice guidance to advise industry and enforcement bodies in areas not currently covered by EU legislation and also help to ensure appropriate training is provided. We have responsibility for food policy and therefore this submission concentrates on food allergy and intolerance. However, the symptoms seen in many people exhibiting allergic reactions to foods include those associated with other non-food types of allergy (such as respiratory and dermal reactions), as well as gastrointestinal symptoms and possibly anaphylactic shock. Proper diagnosis and appropriate dietary avoidance strategies may help to reduce the incidence of respiratory and dermal allergic reactions. There is evidence (Pumphrey, unpublished data) to show that a significant proportion of fatal asthma attacks are triggered by allergic responses to foods that exacerbate existing, poorly controlled asthma. Furthermore, sulphites used in many foods as a preservative are also known to trigger attacks in a proportion of asthmatics. In addition, egg and milk allergies are associated with eczema in young children.
Responses to Questions Posed by the Committee The Agency welcomes the opportunity to provide evidence to this inquiry. We have structured the main part of our evidence around those questions posed by the Committee in its call for evidence that are relevant to our remit.
1. Defining the Problem
What is allergy? What is the difference between allergy and intolerance? 1.1 Although food allergy and food intolerance are both types of food sensitivity, they are diVerent conditions. The main diVerences between them are that food allergy involves the immune system, and specifically the production of IgE antibodies against the food protein in question, whereas food intolerance generally does not involve the immune system. Other diVerences include the length of time it takes for symptoms to appear and the type of symptoms involved. When someone has a food allergy, their immune system reacts to a particular food as if it is not safe. This causes immediate symptoms, which generally include itchiness, rashes and swelling, but can also include more severe respiratory and gastrointestinal symptoms. Sometimes this reaction is so severe that people can experience life-threatening anaphylactic reactions, which aVects the whole body, often within minutes of eating the food, although this can take longer. 1.2 The foods that most commonly cause allergic reactions in the UK are peanuts, tree nuts (such as almond, hazel nut, walnuts, and Brazil nuts), milk, eggs, fish and shellfish but many other foods are also capable of inducing allergic reactions in some individuals. 1.3 Food intolerance generally does not involve the immune system, although gluten intolerance (coeliac disease) is an auto-immune disease. Some food intolerance reactions are caused by an inability to digest a particular food, for example because of a lack of a specific enzyme (such as lactase in people with lactose intolerance), but often the mechanism of the reaction is unknown. Usually symptoms are not immediate although there are some preservatives and flavour enhancers that can cause flushing or wheezing in asthmatics soon after eating. The symptoms can be unpleasant and severe in some cases and they can aVect long-term health, but they are generally not life-threatening. 1.4 People with a food allergy need to avoid all forms and traces of that food, however small the amount. However, people with food intolerances can often tolerate small amounts of the food without noticeable symptoms, although the amounts that can be eaten without symptoms will vary. 150 allergy: evidence
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1.5 There are many foods that people can be intolerant to, but the most common food intolerances are to milk (cows’ milk protein intolerance) and lactose (milk sugar), gluten (a protein found in cereals such as wheat, barley and rye), wheat, food preservatives, and naturally occurring compounds in foods, such as caVeine and some amines.
What is and what is not known about the origins and progression of allergic disease?
1.6 We know the basic immunological mechanisms of food allergy and how reactions occur. Allergic diseases normally develop in two phases. First exposure to the inducing allergen results in a primary immune response (sensitisation) which primes the immune system for subsequent exposure to that allergen. When the sensitised person is subsequently exposed to the same (or a cross-reactive) allergen, there is an accelerated and more aggressive immune response that results in an inflammatory reaction and the clinical manifestation of allergy. The reaction is usually caused by specific IgE antibodies that are reactive with the food protein. These IgE antibodies attach to certain cells in the immune system and bind to the allergen. When they bind to the allergen, there is a resulting cascade of reactions that cause the clinical symptoms of an allergic reaction.
1.7 There are a number of other factors that help to determine whether an individual is likely to develop an allergic condition, including genetics and the ways in which they are exposed to an allergen (route, age and amount). Further details on these factors can be found in Annex I.
1.8 It is diYcult to estimate the proportion of people with food allergy who will experience severe, possibly fatal, reactions. However, the most common identifiable causes of anaphylaxis are foods, medications, insect stings and allergen immunotherapy injections, with anaphylaxis to peanut and tree nuts being of particular concern because of its life-threatening potential. It is reported that one in two children with peanut allergy experience life-threatening symptoms with subsequent reactions. In 2004–05 there were 829 hospital admissions in England caused by anaphylactic reactions to food11 and a recent analysis of trends in admissions to hospital for food allergy has shown an increase of 500 per cent since 1990, with some evidence for an increase in the prevalence of peanut allergy in children. People vary considerably in their sensitivity to particular food allergens, and there is also considerable variability within an individual on diVerent occasions, depending on factors such as the amount of the allergen consumed, the food matrix in which it is present, the underlying health of the individual and other as yet unknown factors. There is evidence to show that allergic reactions to foods can be significantly more severe in people with asthma.
1.9 However areas of uncertainty remain where further research is needed, including the role and importance of other (non-IgE) immunological factors on the regulation of the allergic response and the determination of whether an individual becomes allergic or tolerant to a particular allergen. Other emerging areas of interest include the role of T lymphocytes, including T regulatory cells, in determining immune status, the roles of other classes of antibody, such as IgG, in the food allergic response and an understanding of why proteins diVer in their ability to cause food allergy.
Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such a high prevalence of allergy?
1.10 Although there are a variety of existing hypotheses to explain the rise in the prevalence of atopic (a tendency to produce an IgE antibody response to a range of allergens) allergy and allergic diseases (see Annex I), there is no single agreed cause at the current time. Whilst the UK may have a higher incidence of some food allergies than some other countries, these countries may have a higher incidence of diVerent food allergies. For example, there is a higher incidence of fish allergy in Scandinavia and a higher incidence of rice allergy in the Far East than in the UK. DiVerences in dietary habits and practices are thought to have a major impact on the incidence of particular food allergies in diVerent countries but this is unlikely to be the only causative factor and research is ongoing to look at other possible reasons for observed diVerences. Further evidence on the prevalence of food allergies in the UK is given in Annex I. 11 http://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID%1937&categoryID%214 allergy: evidence 151
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2. Treatment and Management
Is the level of UK research into allergy and allergic disease adequate?
2.1 We cannot comment on the adequacy of research into allergy in general. However we have a food allergy and intolerance research programme, which was established in 1994 by the then Ministry of Agriculture, Fisheries and Food and taken over by the Agency, when it was established in April 2000. The main aims of this programme (designated T07) have been to characterise factors that influence the pathogenesis of these conditions, focussing initially on peanut and tree nut allergy and on the later stages of allergic disease, when allergy has already developed. More recently the programme has been investigating what the prevalence of food allergy in the UK is and whether it is increasing, the factors that govern inter-individual diVerences in susceptibility to food allergy and whether it is possible to identify those at risk of developing food allergy. The programme has also included work on thresholds for sensitivity to gluten in order to better control the composition of foods for coeliac patients that are described as “gluten-free”, the characteristics of kiwi fruit allergy and the possible eVects of some food additives on behaviour in children. 2.2 In 2000, the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment published a report on adverse reactions to foods and food ingredients, which included a number of recommendations for research. Whilst some of these recommendations were directed at clinicians, academia and the Department of Health, others have been addressed within the Agency’s T07 programme. The outcomes from the T07 programme have been summarised in Annex II, but a number of other studies are still in progress. These address a range of important issues, including further investigations on the role of pre- and post natal exposure to allergens in the development of allergy or tolerance to food proteins, and the role of T cell responses in the development of allergic sensitivity or tolerance, the possible eVects of additives on the behaviour of children and thresholds for tolerance to gluten. A list of the projects within the programme can be found in Annex II, and further details about the individual projects can be found on our website12. 2.3 This T07 programme was reviewed by independent experts in 2003 as part of a 5-yearly review cycle. The reviewers were complimentary regarding the outputs from the programme which increased understanding of the prevalence and mechanisms of food allergy and also resulted in specific information that led to improvements in the advice available to those aVected. The review report,13 which was published on the Agency’s website, noted the need for the Agency to work with other funding bodies, both to improve the robustness of the research that is commissioned and to provide better value for money when the funding for such research is limited.
What are the most promising areas of research into preventing or treating allergy?
2.4 It should be noted that, at present, the only treatment for food allergy is avoidance of the food(s) in question. Although desensitisation treatments exist for some allergic diseases, such as hay fever, such approaches are not yet available for food allergies. Medication only deals with symptoms of a reaction once it is happening and medication, such as adrenaline injections, may not be eVective if given too late after the reaction starts. There have been recent reports of work to produce recombinant versions of some of the allergenic proteins from foods that have been modified to reduce their allergenicity, which could then be used to desensitise the body’s immune system (immunotherapy), although actual treatments are still some years away. 2.5 The Agency considers that key areas for research are to determine: — appropriate weaning practices for children, both those with and those without atopic backgrounds, with respect to the timing of introduction of the main allergenic foods, and the frequency and amounts to be given, so as to reduce the risk of allergy developing and promote the development of tolerance; and — thresholds for allergens that can be used by the food industry to inform labelling decisions. The Agency issued a call for research proposals to address these questions in March 2006 and is currently considering possible projects for funding. 12 http://www.food.gov.uk/science/research/researchinfo/foodcomponentsresearch/allergyresearch/t07programme/t07projectlist/ 13 http://www.food.gov.uk/multimedia/pdfs/t07review.PDF 152 allergy: evidence
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3. Government Policies
How effectively are food policy and food labelling regulations responding to the rise in food allergies? 3.1 One of the key aims of the Agency is to enable consumers to make informed choices about the foods they eat. In response to the apparent increase in the prevalence of food allergy and intolerance in the UK, we set out in our Strategic Plan for 2005–1014, that we would work to ensure that people with these conditions have the right information to ensure their safety and to prevent their choices from being unnecessarily restricted. 3.2 The Board of the Agency first discussed food allergy and intolerance at its open Board meeting in February 2003,15 in relation to a need for clear labelling and information, and agreed at that time to develop an Allergy Action Plan. Such a plan was agreed at a further open Board meeting in September of that year16 and updates on progress have been discussed by the Board subsequently in September 200417 and April 2006.18 3.3 The Agency’s Allergy Action Plan incorporates a number of elements, including improving food labelling (both statutory and voluntary), raising awareness of food allergy issues, particularly amongst caterers, and improving training, both for those working in all sectors of the food industry and for Local Authority enforcement oYcers. The Plan also encompasses improving the information available to consumers so that they can understand and use the labelling on the foods they buy. The Board will continue to review the progress of these initiatives and the Action Plan will evolve in response to changing needs. Further details regarding food allergen labelling, both statutory and voluntary, are given in Annex III. 3.4 Enforcement of allergen labelling legislation rests with Local Authorities but investigating incidents to ensure food safety is protected and food is correctly described is a key part of the Agency’s work. If an allergen present in a food is not correctly labelled, the aVected food may be withdrawn or recalled and information is provided to enforcement bodies, and is also published on the Agency’s website. In addition, the Agency works to ensure that consumers with food allergies or intolerances are also informed of such incidents via their consumer support organisations. Food premises, including catering businesses, are inspected and assessed by Local Authority enforcement oYcers, and recent guidance to catering businesses on the implementation of safe catering practices included a section on good allergen control.
4. Patient and Consumer Issues
What impact do allergies have on the quality of life of those experiencing allergic disease and their families? 4.1 People with food allergies and intolerances face a range of dietary and social restrictions, depending on the numbers and types of foods to which they react. There is evidence to show that 9–10 year old children with peanut allergy have a significantly poorer quality of life than children of a similar age with insulin-dependent diabetes mellitus. Peanut allergic children reported more fear of an adverse reaction and more anxiety about eating, especially away from home. They also felt more threatened by potential hazards in their environment and more restricted concerning their physical activities. 4.2 Currently the choice of foods for allergic consumers can be limited and the financial costs for allergic consumers are higher than those who are not on a special diet. An FSA study in 2002 on “May Contain Labelling—The Consumer Perspective” found that nut allergic consumers took an average of 39 per cent longer to shop and paid 11 per cent more for food. 4.3 Consumer research conducted by the Agency in 2005 into the information needs of teenagers with food allergies and intolerances showed eVects on social and inter-personal life, diYculties in fitting in with peer groups and dietary restrictions. Given that many social interactions in this age group are centred on eating and drinking, such conditions significantly impair their quality of life. There is evidence that a significant proportion of adolescents and young adults admit to risk taking behaviours (such as eating foods that carry ‘May Contain’ labelling, a reluctance to ask questions about the allergen content of foods, especially in restaurants, and not carrying their medication), partly in response to a desire to avoid social isolation. 4.4 In addition to providing information for consumers, the Agency also raises awareness of food allergy issues with food businesses and Local Authority enforcement bodies, by providing best practice guidance and helping to ensure that appropriate training is available (see Annex III). 14 http://www.food.gov.uk/multimedia/pdfs/stratplan0510.pdf 15 http://www.food.gov.uk/news/newsarchive/2003/feb/boardmeetingnewsfebruary2003 16 http://www.food.goc.uk/news/newsarchive/2003/sep/boardupdatessept122003 17 http://www.food.gov.uk/aboutus/ourboard/boardmeetings/boardmeetins090904/boardminutes090904 18 http://www.food.goc.uk/news/newsarchive/2006/apr/openboard0406 allergy: evidence 153
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What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? 4.5 Ewan and Clark demonstrated that the adoption of good management plans by food allergic patients (including detailed advice on avoidance strategies, treatment plans and prescription of medication for self administration) reduced the rate of adverse reactions from about 50 per cent to 15 per cent. 4.6 The Agency has produced a fact sheet for those with food allergies and intolerances to help them successfully avoid the foods to which they know they react,19 including information on understanding food labels and advice for when eating away from home. This was made available on the Agency’s website in December 2004 and was subsequently publicised to health professionals via the GP and Chief Nursing OYcer Bulletins issued by the Department of Health. Following feedback from dieticians, the Agency has recently updated this fact sheet, separating the information into two separate documents, one covering food allergies and the other food intolerances. This update was conducted in partnership with the British Dietetic Association and is being publicised to their members via their website. 4.7 The Agency has a consumer-facing website20 that contains a section on food allergy and intolerance issues, including background information on these conditions, and the foods likely to provoke such reactions, as well as advice on buying foods both in retail and catering settings. In addition, there is an ‘Ask on Expert’ function that allows consumers to pose questions which are replied to individually and some of the points raised are incorporated in a Q&A section on the website21. Furthermore, the Agency provides information on its website explaining food labelling, including allergen labelling and information is also provided in the form of leaflets.
Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory? 4.8 We cannot comment on the regulation of diagnostic and therapeutic services. However we receive many requests from consumers who have used over-the-counter allergy tests (many of which have not been formally validated for diagnosing food allergy), seeking advice to help them comply with the recommendations they have been given as a consequence of using these tests, to remove many basic foods, such as wheat and dairy products from their diets. We are concerned that many people follow such recommendations and restrict their diets unnecessarily without receiving proper clinical and dietetic support, which could lead to nutritional problems. We provide advice on our website and in response to correspondence that people should always seek advice from health professionals and dieticians before making major changes to their diet. The issue of un-validated tests was also addressed by the Royal College of Pathologists, who concluded that commercial allergy tests were not recommended and that some were of dubious scientific value. They also concluded that testing for allergy without first knowing a patient’s medical history was poor practice and likely to be unhelpful or misleading.
Annex I
Factors that Influence the Likelihood that an Individual Will Develop an Allergic Condition 1. There is a subgroup of the population with a predisposition towards mounting IgE antibody responses to allergens (atopic individuals). In addition, children whose parents and/or siblings have allergic diseases have a higher risk of themselves developing allergic diseases, although the form that the allergic disease takes may vary, depending on interactions with environmental factors and the nature and timing of exposure to potentially sensitising proteins. 2. One factor that influences the acquisition of atopy is programming of the developing immune system in the young infant. There is some evidence that increased protection of infants from pathogens and environmental non-pathogenic micro-organisms is associated with an increased prevalence of atopy (the so-called hygiene hypothesis). However, there is no unifying hypothesis concerning the exposure to overt viral and bacterial infection, the significance of environmental exposure to microbial compounds and the responses of the innate and adaptive immune processes. A recent review of evidence points to the view that fundamental changes in lifestyle that have led to decreased exposure to certain microbial or other species, such as helminths, rather 19 http://www.food.gov.uk/multimedia/pdfs/avoiding food.pdf 20 www.eatwell.gov.uk 21 http://www.food.gov.uk/asksam 154 allergy: evidence
31 January 2007 than infection with pathogenic organisms or changes in domestic hygiene are important for the development of immunoregulatory mechanisms. Food safety measures are generally targeted at pathogens and do not aim to produce a sterile environment. 3. We do not know definitively why the prevalence of atopic allergic disease has risen in recent years but other possible causes include changes in diets and the introduction of “new” foods (eg peanuts in the 1940’s and kiwi fruit in 1970’s) may have led to an increase in the prevalence of some food allergies. Peanuts are now commonly eaten roasted rather than raw, and roasted peanut is known to be more allergenic than raw peanut. 4. Some individuals have been reported to react on their first known exposure to peanut, generating the hypothesis that maternal transfer of the allergen or immunological components may be an important factor in the development of food allergy. It is recognised that intrauterine immunological sensitisation can occur and that transmission of food allergens to infants via breast milk in an un-degraded form may be a route of neonatal sensitisation. Research on the influence of maternal diet during pregnancy and the development of food allergy in the oVspring is still inconclusive and the Agency is currently funding research in this area. Peanut allergy is highly associated with a family history of allergic disease, and it is currently not possible to discount the possibility of a link between consumption of peanut by the mother during pregnancy and lactation and the incidence of peanut allergy in the oVspring. Therefore the Government issued precautionary advice to mothers in 1998 to avoid eating peanuts and peanut products during pregnancy and breastfeeding if their child had a family history of allergic disease. 5. Other factors that may be important in the development of food allergy include the age of first exposure to the allergenic food and the route of exposure. Weaning practices have changed significantly over the last 50 years, with evidence suggesting a trend towards the later introduction of solid foods, including commonly allergenic foods. There is currently a lack of evidence on the optimum times to introduce the common allergenic foods into the weaning diet, either in children from atopic or non-atopic backgrounds. Given that there is currently no cure for food allergy, it is important that evidence-based advice on the introduction of allergenic foods into the weaning diet is developed so as to minimise, where possible, the number of children that develop food allergy. The Agency called for research proposals to address this question in March 200622 and is currently considering possible projects for funding. 6. Recent research has demonstrated that dermal exposure may be an alternative route of sensitisation for food allergens (especially peanut), perhaps through use of creams/oils or through general low level environmental exposure if others in the household are eating peanut. Such low level dermal exposure, especially to broken skin, is associated with sensitisation and clinical allergy whereas high level oral exposure may lead to tolerance. 7. Furthermore there may also be an increase in occupational exposure to allergens, such as latex, which is known to cross react with a number of fruit allergens associated with oral allergy syndrome. In addition exposure via inhalation may be important in some situations, for example those preparing and cooking fish may react to the vapours produced.
Prevalence of Food Allergies
8. It appears that there has been an increase in the incidence of at least some food allergies in recent years, which is in line with the general increase in the prevalence of atopic allergic diseases. An increase in clinical peanut allergy in early childhood from 0.6 per cent in 1989 to 1.5 per cent in 1994–96 has been reported in the UK, with rates of sensitisation increasing from 1.1 per cent to 3.3 per cent over the same period. Peanut allergy is reported to be presenting earlier in childhood and is more common in siblings of people with peanut allergy. There is a similar situation in the US where the prevalence of peanut allergy was found to have doubled in American children under five years of age over a five year period. 9. Definitive figures for the prevalence of individual nut allergies in the UK are currently lacking. Peanut allergy is the most common cause of severe (fatal and near fatal) allergic reaction to foods. The Agency is funding projects to determine the current prevalence and incidence of specific food allergies in the UK and whether food allergy has increased in the last 20 years, including studies to investigate the eVect on the incidence of peanut allergy of the issuing of the Government advice on the avoidance of peanut during pregnancy and lactation by mothers whose child has an atopic family background. One of these projects is 22 http://www.food.gov.uk/multimedis/pdfs/rrd21 allergy: evidence 155
31 January 2007 part of a large European wide study (Europrevall23) funded by the European Commission’s 6th Framework Programme. This will provide definitive data on the current incidence of a number of food allergies amongst children and adults across Europe (nuts will be included). The project is due to end in 2010 and the Agency is funding the UK birth cohort from this study.
Annex II
Food Standards Agency Research Programme
1. This programme has extended and deepened knowledge and understanding of the prevalence and mechanisms of food allergy, and has revealed new information about diVerent food allergies, and their causes and mechanisms, which has led to improvements in the advice the Agency provides. In particular the programme has: — Provided evidence that dermal exposure to allergens such as peanut, especially on broken skin, is a risk factor for the development of peanut allergy. Such exposure includes the topical application of creams containing peanut oil and possibly also low level environmental exposure to peanut allergens in the home if peanut products are consumed by other family members. — Investigated the role of maternal diets in the initiation of allergic disease. Early studies indicated that the majority of peanut allergic individuals react to their first known exposure to peanut and that it is not possible to rule out a link between consumption of peanut by the mother during pregnancy and lactation and the incidence of peanut allergy in the oVspring. The Government therefore issued precautionary advice in 1998 for pregnant and breast feeding mothers whose children had a family history of allergic diseases to avoid consuming peanuts. However, subsequent studies have failed to demonstrate a conclusive link between the development of peanut allergy in children and the levels of circulating peanut antibody in the mothers’ blood or breast milk. Other studies have failed so far to demonstrate a link between maternal exposure to allergen and the development of food allergy in their oVspring. However the Agency is funding a further study on egg allergy to follow up preliminary data suggesting that the level of exposure to the allergen might be critical in determining any eVect. These studies have also demonstrated the diYculties faced by mothers who try to completely avoid common allergens such as egg or milk. Studies have also investigated the impact of the Government advice on peanut avoidance during pregnancy and lactation and the subsequent prevalence of peanut allergy in children and these are expected to be published shortly. — Investigated sensitivity in the same subjects to peanuts and tree nuts, showing that multiple sensitivity occurs via sequential sensitisation rather than being due to immunological cross- reactivity. In general, children have been shown to develop sensitisation to peanuts first and then go on to develop sensitivity to one or more tree nuts. This has important clinical and policy implications and the advice for children sensitised to one type of nut is now to avoid ingestion of all types of nut. Children with nut allergy should be periodically monitored for the development of multiple nut allergies. — Investigated the roles of T lymphocytes and IgG antibodies in the development of tolerance to food allergens. Many children with egg or milk allergy in early life lose their allergy by age 5 years but allergy to peanut is often life-long. Several current Agency-funded studies are investigating the mechanisms involved in the development of tolerance. — Characterised kiwi fruit allergy as a new food allergy in the UK. We commissioned work to investigate this emerging food allergen which confirmed that kiwi fruit should be considered a significant food allergen capable of causing severe, life-threatening reactions. Furthermore, in the UK, children are more likely to experience severe symptoms to kiwi fruit than adults, possibly because of the age at which they were first exposed to this allergen. The information has been published in the scientific press so that clinicians will be better aware of kiwi fruit allergy (as a relatively new allergy), its characteristics and how to recognise and diagnose the allergy, which will in turn improve consumer safety. Information for consumers is also published on our website. 23 http://www.europrevall.org/ 156 allergy: evidence
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Areas for Future Research 2. Nutritional status in early life has been associated with general respiratory health in childhood. It is possible that nutritional factors may modify immune function and the susceptibility to develop atopic disease, such as asthma. The Agency is currently in contract negotiations to commission research on the influence of nutrition on respiratory health and asthma in childhood. The aim of the study will be to determine how maternal, infant and childhood diet influences respiratory health in the first seven years of life. It is expected that the results of the study will be available from mid 2010. 3. There is some evidence that early introduction of significant amounts of a food allergen as part of a weaning diet may help to promote the development of tolerance to food allergens but definitive evidence to support this, and an understanding of the optimal ages is lacking. We issued a call for research to address this issue in March 2006 and are currently considering possible projects for funding. Opportunities for joint funding are being investigated. 4. There is at present, a lack of data on individual clinical thresholds for the main food allergens. There is also a lack of agreement on threshold levels of allergens present in foods that should be used for deciding whether or not allergen labelling is appropriate. This information is urgently needed to inform both advisory labelling to warn consumers of possible allergen cross-contamination (“May Contain” labels) and the criteria needed to be able to designate a food as “free from” a particular allergen. In addition, information on levels of allergens for use as a basis for decisions on labelling will help to ensure that foods are not unnecessarily labelled when only a very low level of the allergen is present, which would restrict consumer choice. There needs to be international agreement of both the threshold levels of allergens in foods above which they need to be labelled, in order to protect allergic consumers, and on how these levels should be derived, given the significant inter and intra-individual variations that exist. We have issued a call for research proposals to address this issue and are currently considering how to take this forward. 5. There is also a need for validated detection methods for the main food allergens and for standard reference materials to calibrate such methods, and some work on this is being undertaken by the EU. The European Committee for Standardisation (CEN) is currently working on the development of standards to harmonise the development and validation of methods for the detection and quantification of food allergens. In addition, the European Commission’s Joint Research Commission has been working on the evaluation and comparison of allergen methods currently on the market and the development of certified reference materials to improve the performance of existing and future methods.
List of Projects from the T07 Research Programme
Project code Project Title T07001 The prevalence and natural history of peanut allergy and investigation into its genetic, environmental and immunological determinants. T07002 Development of food intolerance in atopic and non atopic families: influence of maternal nutrition and infant feeding practices in preterm infants. T07003 Investigation of the immunological mechanisms in cow’s milk sensitive enteropathy. T07004 Do food additives cause hyperactivity and behaviour problems in a geographically defined population of three year olds? T07005 The eVect of exposure to food proteins via maternal sources in the development of food allergy in infants. T07010 Cross-reactivity in peanut allergy. T07011 Immunochemical reactivity to peanuts and nuts in allergic individuals. T07012/T07013/ Investigation of the cross reactivities toward peanut and other nuts in relation to the T07014 age of the allergic individuals. T07015 Peanut allergens associated with provoking clinical symptoms. T07016 Investigation of Immune Responses to Food Allergens in Individuals with a Clinical Spectrum. T07018 Allergen specific antibody binding characteristics and longitudinal serological changes to purified peanut allergens. allergy: evidence 157
Project code Project Title T07019 Do protein structures determine the allergenicity of the alpha-class family of plant proteins? T07022 Can topical exposure to peanut antigens induce allergic sensitisation alone or in combination with mucosal exposure? T07023 Prevalence and incidence of food allergies and food intolerance. T07024 Development of a polymerase chain reaction based method for the identification of peanut in commercial products. T07025 The characteristics of kiwi fruit allergy. T07026 To investigate the influence of maternal experience of dietary antigen on the subsequent immune status of their oVspring. T07027 The interaction of food allergens with the epithelium of the alimentary canal: Investigation of non-immunological determinants of allergenicity. T07028 The influence of dose and route of exposure on the early life origins of peanut allergy. T07032 The role of IgG in allergy and tolerance to common food allergens. T07033 The immunomodulatory role of maternal IgG in infant atopic programming. T07034 An investigation into trends of peanut allergy incidence in the last 15 years in England using sequential childhood cohorts. T07035 The prevalence of peanut allergy in British children at school entry age in 2003. T07036 Development, recognition and significance of IgG antibodies in allergic sensitisation and adverse reactions to peanut. T07037 Fatal Asthma from Food Allergy. T07038 The characteristics of kiwi fruit allergy. T07039 Aberrant mast cell signalling as a cause for anaphylaxis. T07040 Chronic and Acute EVects of Artificial Colourings and Preservatives on Children’s behaviour. T07041 The role of peanut-specific T cell responses in children with peanut allergy and in children who are tolerant to peanuts. T07042 Longitudinal Study of T cell responses in development and resolution of Food Allergy. T07043 Peanut allergy: routes of pre-natal and post-natal exposure. T07044 Peri-natal egg and milk allergen exposure patterns and the development of tolerance or allergic sensitivity to food in infancy. T07045 Food Allergy and Intolerance Research—qualitative research into the information needs of teenagers with food allergy and intolerance. T07046 The prevalence of food allergy and weaning practises in a birth cohort of UK Infants. T07048 Systematic review on tolerable levels of gluten for people medically diagnosed with coeliac disease. ZT0702 Allergy Database Service.
Annex III
Food Labelling—Statutory and Voluntary 1. The UK has been pressing the EU for improved labelling of allergenic ingredients in food for a number of years. In 2003, an EU Directive was agreed that required the labelling of 12 specified allergenic foods and their derivatives, whenever they are used in pre-packed foods, regardless of the level of use. A key element of this new legislation was the removal of the exemption in the previous labelling Directive, whereby the ingredients of a compound food ingredient (such as a sponge finger in a trifle, or slices of sausage on top of a pizza) did not have to be declared if the compound ingredient made up less than 25 per cent of the final food product. 158 allergy: evidence
2. This list of allergenic foods was based on advice from the European Food Safety Authority (EFSA) about the foods that are of the greatest public health concern across the European Union countries. This list currently includes the following allergenic foods and any ingredients derived from them: — Cereals containing gluten — Crustaceans — Fish — Eggs — Peanuts — Soybeans — Milk — Nuts — Celery — Mustard — Sesame seeds
— Sulphur dioxides and sulphites at levels above 10mg/kg or 10mg/ml, expressed as SO2 3. This European Directive (2003/89/EC) came into force in November 2004 and products not complying with its requirements were prohibited from November 2005. A further Directive (2005/26/EC) was agreed in March 2005 that exempted certain ingredients derived from these allergenic foods from these labelling requirements, on the basis of evidence that they were no longer allergenic. 4. The European Commission has recently agreed that this list of allergenic foods should be extended to include molluscs and lupin, as there is advice from EFSA that these also present a public health concern. The national implementing legislation will be amended in due course once the EU Directive has been published in the OYcial Journal, which is expected to be before the end of 2006. 5. The statutory legislation described above does not cover unintentional cross contamination of a food with an allergenic food at some point during production. Many food manufacturers voluntarily provide information on such a possibility with advisory labels using phrases such as “May Contain Nuts”. The Agency has conducted consumer research, which demonstrated that many consumers find the variety of phrases used for such labelling confusing, and are concerned that they are overused, and many therefore ignore such warnings. The Agency was also approached by food industry trade bodies asking for advice in this area. 6. The Agency has worked with all the relevant stakeholders to produce best practice advice on allergen management and consumer information, and this was published in July 2006. This guidance helps businesses assess the risk of possible allergen cross-contamination of prepacked foods and also advises them on how such risks can be reduced or eliminated, so that advisory labelling is only used when there is a real risk of cross- contamination that cannot be controlled. The guidance also advises on the phrases to use if such warnings are appropriate, as research has shown that consumers were confused by the wide range of advisory labels currently in use. 7. Foods that are not prepacked (that is foods that are sold prepacked for direct sale or those sold loose, including foods sold in catering establishments) are also exempt from most food labelling legislation, including the allergenic ingredients labelling legislation described above. There is clinical evidence to indicate that foods sold in this way are more likely to be the cause of adverse reactions to foods than foods sold prepacked. In addition, responses to public consultations have indicated that there is strong consumer demand for more allergen information for foods that are not prepacked. 8. The Agency produced advice for caterers on food allergy that was published on the Agency website in May 200424. The Agency is now working with relevant stakeholders to produce best practice guidance on the provision of allergen information for foods that are non-prepacked. A public consultation on draft guidance was issued on 5 July and closed on 27 September 200625. The responses received will be assessed and the draft guidance amended as necessary. It is anticipated that the final guidance will be published in Autumn 2007.
Reference List [not printed] 5 October 2006
24 http://www.food.gov.uk/safereating/allergyintol/caterers 25 http://www.food.gov.uk/consultations/ukwideconsults/2006/allergeninfoconsult allergy: evidence 159
31 January 2007
Examination of Witnesses Witnesses: Mrs Sue Hattersley, Head of Food Allergy Branch and Miss Gill Fine, Director of Consumer Choice and Dietary Health, Food Standards Agency; Ms Andrea Martinez-Inchausti, Assistant Director of Food Policy, British Retail Consortium; Dr Ian Leitch, Chartered Environmental Health Practitioner; and Mr Les Bailey, Food Policy Officer, Local Authorities Coordinators of Regulatory Services, examined.
Q381 Chairman: Good morning and thank you for Q382 Chairman: Could I start of by asking you as a coming. Can I welcome those of you who are giving panel whether there is any evidence that there may be evidence to us today and also members of the public a link between changes in the modern diet and an who have come to listen in on this session. This is the increase in the incidence of asthma and allergy? sixth hearing of our inquiry into allergy. There is an Would you like to start, Mrs Hattersley? information note of the declared interests of Mrs Hattersley: There is evidence that the prevalence members of the Committee so we will not be of diVerent food allergies does vary in diVerent repeating those today during our evidence session. I countries, depending on dietary practices. We would like to ask those of you who are here to start know that weaning practices have changed very V o by giving us a short introduction with your name significantly in the UK over the last 50 years. There and where you are from. I also remind you that this is evidence that diVerent weaning practices across session is being webcast today, so it is being diVerent countries might lead to diVerent incidence broadcast. Could I invite you to start, Mr Bailey. of food allergy. If you look for instance, at Jewish Mr Bailey: I am Les Bailey from the Local children in the UK, there is a very diVerent incidence Authorities Coordinators of Regulatory Services. of peanut allergy in that group compared to Jewish We are the central local government body that children in Israel, where they use a peanut snack as a acts to try to co-ordinate the activities of local V authority environmental health and trading weaning food. There are very clear dietary di erences V standards departments. I deal with food standards, in di erent countries. We also know that the food composition and food labelling issues, which introduction of new foods into the diet can lead to includes allergens. My previous background is in new allergies and we have done some research on kiwi trading standards. which is an emerging allergen in the UK. We also Dr Leitch: I am Ian Leitch. I come from an know that cooking practices can change the environmental health background from Omagh allergenicity of certain foods. Roasted peanut, for District Council. I am presently project manager for example, is much more allergenic that raw peanut, a food allergy project to train environmental health but cooked egg is less allergenic than raw egg. oYcers in food allergen control. That is sponsored by Ms Martinez-Inchausti: I would agree with what Sue Safefood which is the Ireland food safety body and has said. What has also triggered an increased by the EU through a programme called CAWT amount of allergies has been the increase of which stands for Co-operation and Working awareness both by paediatricians or practitioners Together and it is for training in the border regions. and consumers, and the development of methods to I come from an environmental health background diagnose those allergies has also triggered an increase with a particular interest in allergen control. in the numbers. Ms Martinez-Inchausti: My name is Andrea Martinez-Inchausti and I represent the retailers. I am here representing the British Retail Consortium Q383 Chairman: I wonder whether there is any which is the trade association that represents retailers evidence that sulphites and preservatives, possibly to both governmental and non-governmental bodies. even including things like trans fats in pre-packaged I work as the Assistant Director of Food Policy and foods aVect allergy suVerers, and in which foods are I deal with the majority of the technical legislative they found? issues. My background is veterinarian. Mrs Hattersley: We know that sulphites can trigger Miss Fine: My name is Gill Fine. I am Director of asthma attacks in people who already have asthma Consumer Choice and Dietary Health at the Food Standards Agency. The Agency was set up in 2000 to and that is why sulphites are included on the list of protect the health of the public in relation to food and allergens that have to be declared in pre-packed drink and also to reflect their interests. I head up a foods. If sulphites are added to foods that now has to group of three divisions, one of which covers food be labelled so that people can avoid those foods. allergy as part of its remit. My background is as a nutritionist. Mrs Hattersley: I am Sue Hattersley. I am also from Q384 Chairman: Could foods be modified to remove the Food Standards Agency. I head up the Allergy such substances from them so that we would remove and Intolerance Branch within the Agency so I have the substances potentially contributing to allergic the overall responsibility for that area of work. disorders? 160 allergy: evidence
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey
Mrs Hattersley: It is very diYcult. There has been the general environment so that may be leading to some work done to look to see whether they could sensitisation at those very low levels. remove some of the allergenic proteins from peanuts but we know that there is not just one protein in the Q388 Lord Taverne: What about the eVect of latex- peanut, there are perhaps half a dozen diVerent containing packaging? Is that possibly something allergenic proteins. If you try to breed a peanut that which could trigger dermatitis or exacerbate it? has less of one protein it may be producing more of Mrs Hattersley: We know that there is an increase in the other proteins and very often in the nuts and seeds latex allergy in healthcare workers, for example, who it is the storage proteins which are allergenic so there wear a lot of latex gloves. There is also work being tends to be very high levels of those proteins in the done to look at latex allergy in food handlers because foods. some food handlers wear gloves. The Agency has done some research to try to develop a methodology Q385 Lord Taverne: What research is the FSA for looking at levels of latex in packaging materials, supporting to identify the characteristics of foods to see whether that transfers into the food. At the which can lead to the development of food allergy moment we are starting to develop that methodology and intolerance? and there is a further project underway at the Mrs Hattersley: We know that most food allergens moment trying to develop that further so that we are proteins so we have done some research to look have a reliable test to see how much latex might be at the characteristics of proteins that make them getting into the food. allergenic and there are certain characteristics which tend to be associated with allergenic proteins. They Q389 Lord Taverne: What is your method of dealing tend to be resistant to digestion; they tend to be with proposals for research into allergy? Do you take present in very large amounts; they tend to have unsolicited proposals or do you only support multiple binding sites for the IgE antibodies. Some contract studies? non-allergenic proteins also have very similar Mrs Hattersley: Normally we issue open calls for characteristics so we think there are other factors research proposals, the Agency will do that on a involved as well. Other molecules attaching to the regular basis. Three or four times a year we will issue protein aVect the allergenicity as well, so it is still an calls for proposals, which may include calls on food area of on-going research. allergy. People submit their proposals and they are independently appraised before we contract any Q386 Lord Taverne: I gather that some of your research. People can also come to us if they have research has been into early life exposure and particular research ideas. One of the examples was pregnancy exposure which suggests that low level the work that we did on kiwi allergy. Somebody came environmental exposure to allergens can actually to us asking whether they could do a pilot study to lead to sensitisation, rather the opposite, as it were, of look at the characteristics of kiwi allergy and we some early exposure leading to immunity which we funded that. Then we funded further study into it found with farm animals and possibly with peanuts. because it looked like there was an issue there. It can Mrs Hattersley: There is certainly some evidence be via either route. indicating that low level environmental exposure to some of the allergens, particularly peanut, may cause Q390 Earl of Selborne: Still on the subject of sensitisation, whereas if you have higher dose oral research funding for proposals, there must be a lot of exposure then that may lead to tolerance. This is the international work in this field and I wonder whether evidence that we are getting from the study of Jewish the FSA is confident that it can keep in track children in Israel, where they use the peanut snack as with other relevant research in other countries, a weaning food. It found that if you have a high level particularly for example with something like the kiwi oral exposure that actually leads to the development fruit you have just referred to. Presumably one would of tolerance, whereas if you have just a very low level go to South Africa or New Zealand or somewhere to exposure—sometimes dermal exposure—that may look at some of the work on relevant populations. be leading to sensitisation. Mrs Hattersley: In running our programme we have an independent adviser who is an expert in the allergy Q387 Lord Taverne: Dermal exposure to peanuts? field so he helps us to keep up to date with the Mrs Hattersley: Yes. We know that peanut oil used to literature. We also scan the literature ourselves to see be used in creams for eczema. Also a lot of natural what work is being done elsewhere. As I said, when cosmetic and toiletry products have nut oils in them, we call for proposals for new research we do have so that may be another route of exposure. Also, if them independently appraised by external experts, so other people in the household are eating peanuts then again it is bringing their expertise in to look at the there may be peanuts on people’s hands and it is in work people propose to do so that we make sure we allergy: evidence 161
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey do not duplicate work that has already been done matrix and whether the type of food that the allergen elsewhere. is in makes a diVerence. They are also looking at quality of life issues. We are collaborating with them Q391 Viscount Simon: You mentioned IgE. In your but by funding one particular arm of the study in the submissions in the T07 research programme you put UK we have access to all that information so the IgG. I wonder if you could explain the diVerence and collaborative research is a very good way of making why it is included in your research programme. our money go further. Mrs Hattersley: The IgE response is typical of the allergic reaction, in that you are producing those Q395 Lord Colwyn: I am aware that the UK has particular types of immunoglobulin proteins in been pressing for improved labelling of allergenic response to the challenge with the allergen, but it is ingredients in food. How do current labelling not just the specific IgE that is produced in response regulations recognise allergens in foods? Who to, say, peanut or egg that seems to be relevant to the decides at what level an allergen must be listed? We level of response seen in an individual. We think that have a list from the FSA here and I notice, for IgG may help moderate that response but it remains instance, that kiwi fruit is not even included. unclear how, and certainly there are what are called Miss Fine: The current regulations require T regulatory cells which are particular types of declaration of ingredients when they have been lymphocytes which also help moderate the immune deliberately added and there is no threshold for that. response. It is a matter of looking at how that If a manufacturer or retailer is using a food or response is triggered and all the other factors that ingredient that contains these allergens it must be might moderate it. Both the IgG and the regulatory declared on the label. The way in which that list is cells seem to be implicated in the development of determined is that, because labelling is an EU tolerance and we are trying to do some research to see competency, the European Commission asks the why it is that some people outgrow their allergies (egg European Food Safety Authority for advice on and milk allergies are often outgrown by the time the which of the allergens are of public health concern child is five) and so if we can understand how that across all Member States and that is where the initial tolerance develops then we might be able to do list of 12 allergens came from. Subsequently there something to moderate the types of reactions that have been another two added in December last year. happen. I think the key thing here is that it has helped to improve the clarity of the label for consumers so Q392 Chairman: What is the research budget for whereas before it would say “casein” in the food allergy research in the UK? ingredients it now says “casein from milk” so it helps Miss Fine: The research budget for the allergy work the consumer understand more clearly where those is around £1 million each year and that represents particular allergens are coming from. about five per cent of the Agency’s research budget. I should add, in response to the work on the Q396 Lord Colwyn: What are the other two that international side, we are very keen that we get the have been added? best value for money from the research, so Miss Fine: Molluscs and lupins have been added to increasingly we are looking to see how we can work the list. There will be a period of time before which collaboratively with activities that are happening in the manufacturers and retailers have to declare it but Europe and internationally. they have now been added to the list.
Q393 Viscount Simon: Is £1 million a year enough? Q397 Lord Colwyn: Obviously sensitivity levels for Miss Fine: Research is quite a hungry beast and the allergens vary amongst individuals. Would it be a Agency funds research across a wide range of food good idea to define a level above which the packaging issues. We are very keen that we carry on with the must list any particular allergen? research in this area. £1 million is a significant Mrs Hattersley: The legislation for the pre-packed amount but whether it is ever enough I think is very food is that the allergen has to be labelled regardless hard to say. of the level of addition, if it is deliberately added as an ingredient. The science at the moment is not yet Q394 Chairman: How does that compare to the US able to let us set thresholds for the allergens in food. or European budgets, do you know? We have guidance on the advisory labelling to cover Mrs Hattersley: I am not sure about the budgets in the possible cross-contamination but at the moment we US but we are part of a very large EU framework do not really have enough evidence to set even the programme which I think has about £12.5 million clinical thresholds for the allergens (below which an worth of research looking at the prevalence of food individual would not react). As you say, individuals allergy and it is also looking at things like the food vary very considerably in their response, so it is how 162 allergy: evidence
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey you would turn that information into a management Q402 Lord Broers: So it is not labelled below that. level that the industry could use. We do not yet have Mrs Hattersley: No. That is the one allergen in the list the scientific evidence to be able to do that but we are that does have a threshold. actually working with this European consortium that Ms Martinez-Inchausti: As Sue said, sulphites is the we mentioned earlier and are holding a conference only one for which a maximum level has been set this summer to look at that whole question of how under the European legislation. It is very diYcult to you actually set the threshold levels for the food set levels at the moment because of the lack of because you have to work out the safety factors that information that we have. Attempts have started to you need to include in those calculations to protect try to set up a level for gluten and there is an the most sensitive individuals. Risk assessment in international body called Codex Alimentarius which that way is fairly well established for chemicals, for has a draft proposal to set a level for gluten for over toxicological evaluations, but no-one has yet tried to 20 ppms. There are associations which have been apply that to allergens so this conference is going to using that level, for example Coeliac UK, to be pulling together experts from around the world so determine whether something is gluten free or not. there will be European and American experts there to However, if you were to apply the legislation help us discuss how you actually do that risk accurately any possible level of gluten present in food assessment. It is something that is in progress and we should be labelled if the ingredient is deliberately know it is something that does need to be done. added. It is the only allergen on which they are actually doing some work. With other allergens, for example nuts, the sensitivity to that specific type of Q398 Lord Colwyn: You refer to “we”; that means allergen is so, so delicate and small that anybody the FSA does it? could trigger a reaction with a very minute amount Mrs Hattersley: Yes26. and it would be impossible to set a level.
Q399 Lord Colwyn: Who else is researching these Q403 Lord Colwyn: Does this extend beyond foods threshold levels? to things like ointments and toothpaste and things Mrs Hattersley: Academics are doing research in that that are not necessarily always ingested but could be? area and certainly other government authorities are Mrs Hattersley: No, the legislation applies to food. doing work as well. The EU have announced that they are reviewing food labelling and there was a suggestion that they would Q400 Lord Colwyn: You keep in touch with include non-food products in that but I am not sure other research facilities throughout Europe and how widely that has been taken forward. It was in throughout the world. their original proposal that they might look at some Mrs Hattersley: Yes. We scan the literature and other products. through these international consortia we are in touch with other people working in the area. Q404 Chairman: Going back to your comment about trans dermal, were cosmetics included and all of the so-called skincare products? Q401 Lord Broers: Labelling at too low a level can Mrs Hattersley: They are not part of the Food render the label relatively useless. This is the case with Standards Agency’s remit. I think they come under sulphites in my experience. I declare an interest, being the Department of Trade and Industry. There are allergic to sulphites. You find that in almost every controls on cosmetic and toiletry products. product it says there are sulphites there whereas it is Mr Bailey: There is an EC Cosmetics Products only above a given concentration that most people— Directive which is implemented in the UK through I think almost all people—are allergic to sulphites, so UK legislation and that sets out general controls over by labelling everything as containing sulphites makes the safety of a whole range of cosmetic products the labelling virtually useless. including their composition. Mrs Hattersley: Sulphites actually are the only allergen in the list that does have a threshold, so it is Q405 Baroness Perry of Southwark: You mentioned when it is added above 10 parts per million that it has the issue of cross-contamination and for defensive to be labelled. reasons food manufacturers nowadays do tend to put 26 Guidance on Allergen Management and Consumer “may contain nuts” simply because there could be Information (“May Contain” Labels)—We should also like to clarify that “May Contain” was produced by the Food some cross-contamination. It does make it very Standards Agency, working in collaboration with stakeholders, limiting for people who have allergies if they see that including the Food and Drink Federation and the British Retail on a packet. Is there anything being done to minimise Consortium. We are grateful to them for producing the first draft of the document, which was based on their own previous this risk of cross-contamination, for example is there guidance. any thought of bringing in legislation or regulation to allergy: evidence 163
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey ensure that food manufacturers have separate believe that the scope of the labelling Directive production lines for things which contain nuts and should be extended to cover consumer information things which do not. and within that scope the provisions on having to go Ms Martinez-Inchausti: First I would say that we through a risk assessment, having certain risk firmly believe that the warning should be the last management controls in place and being able to resort and that is the basis on which our members identify whether a warning is necessary is one of the operate. We strongly believe that a warning should areas they are considering to be included in future not be a substitute for controls or for good practice legislation. and we take the subject very seriously. We do not believe it is useful for the customer to have a “may contain” or equal warning splashed out on absolutely Q407 Baroness Perry of Southwark: There is a all the labels, so they would only use it when there related issue—I speak with feeling because I have a gluten intolerance myself; we seem to be a Committee really is a risk. The area of allergens is fairly new and V I think we are all learning to see how it should be of people with di erent allergies and intolerances—in handled and controlled; we are all learning to that some manufacturers do continue to list gluten or understand allergens. Taking advice and gaining wheat or something in the box even when it is the from the experience of some manufacturing and kind which has already been made exempt by the retail companies that are ahead of the game both the European Food Safety Authority. I suppose they Food and Drink Federation and the British Retail feel, in a defensive way, they need to mention that it Consortium decided to take the initiative to write is there. It is very confusing when you see things like some guidance to try to put on paper advice for other that on a package or a box; is there not some way to members of the industry on best practice to control make it clearer as to what you can eat and what you the cross-contamination or the possible cross- cannot? contamination of allergens within industry. The Mrs Hattersley: As Andrea said, the Agency has most important part is to identify where cross- worked with food manufacturers and retailers and contamination occurs and once that is identified to with the consumers and the enforcement people to set up control levels to try to minimise it. There are a produce this guidance that we published last summer. lot of initiatives and a lot of actions which are taking That gives very clear advice to the businesses on how place from training the staV, from labelling all of the to assess the risks of cross-contamination and try to ingredients as soon as they come into the factory, minimise those risks so that they only put the segregation of those ingredients, separating lines to advisory warning on when they cannot control the changing the scheduling of production. One example risks. I think we have to recognise that the food chain could be in chocolate manufacturing. Chocolate is very long and complex in some situations, going manufacturers tend to produce both plain chocolate right back to the fields where the food is grown and and milk chocolate. The way it has been produced up the way it is harvested and transported. There are to now is that they would produce the milk chocolate, risks of cross-contamination very early in the food clean the line and then produce plain chocolate chain in some examples. What we have done in the afterwards. Simply by changing the way in which the guidance to try to help consumers is, we have advised chocolate was produced by doing the plain chocolate that if manufacturers feel that there is a risk of cross- contamination that they only use one or two phrases. first, cleaning it and doing milk chocolate afterwards V has significantly reduced the risk of cross- We know that consumers see all the di erent phrases contamination of milk on the plain chocolate. There like “may contain” or “not suitable for” or “made in the same factory” and find them very confusing are a lot of initiatives that are taking place and we are V trying—together with the FSA who subsequently because they think there are di erent levels of risk sponsored the guidance we wrote with the help of and are not able to evaluate that risk. We advise just LACORS and the Anaphylaxis Campaign—to two very simple phrases to use so that should be create awareness and help for the business gained clearer for the consumer. from experience. Mr Bailey: Local authority food enforcement oYcers, be they trading standards oYcers or environmental health oYcers, visit all 600,000 Q406 Baroness Perry of Southwark: I can see that registered food businesses in the UK on a regular you are doing a lot to oVer guidance and so on, but basis. Although we are there really primarily looking do you think there is a case for providing incentives at the statutory requirements we also advise on best or even regulations which would minimise this kind practice and so we would draw attention to the of risk? guidance document which has been produced. Also Ms Martinez-Inchausti: The labelling is certainly in the course of inspections you would be able to being reviewed in Brussels at the moment and in the identify where some of the critical control points are last discussions that had with the Commission they and the situations where cross-contamination may 164 allergy: evidence
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey occur and be able to advise the business. Hopefully sweets would perhaps be inspected once every two or that will try to reduce down the number of examples three years. It is all related to risk. where this defensive labelling is used. Dr Leitch: If I can follow on from Les’s comment, the enforcement oYcers are visiting the businesses but Q410 Baroness Platt of Writtle: The European this is a very complex area and it is very important Union is currently examining how to make food that the enforcement oYcers receive detailed training labelling clearer and more consistent. What so that they are giving the correct advice to the trade. involvement will the FSA have in the development of That is my background at the minute, training. I feel new European Union legislation and will the new that with the best will in the world unless you have the regulations consider allergens? enforcement oYcers properly trained you can run Miss Fine: The EU is reviewing all food labelling. into dangers of a false sense of security where you Over the years various pieces of legislation have think the businesses are doing the right thing when grown up in a rather piecemeal fashion so this gives they are not. an opportunity to review all of that and to rationalise it into one piece of legislation. It also gives an opportunity to see what information is essential and Q408 Lord Taverne: Coming back to defensive must be provided for consumers and other groups, labels and the common label “may contain nuts”, is and what information could be provided elsewhere. that necessary because of the ghastly consequences or The safety information, which would include allergy, is it not particularly helpful? is a key part of that. The Agency’s role is that we are Mrs Hattersley: If there is a risk of cross- the lead UK government department on food contamination, for instance in chocolate there could labelling so we will be taking forward the be a large piece of nut in a chocolate that is not negotiations and as part of that process we will be supposed to contain nut and certainly that amount of consulting with a wide range of groups—consumers, nut would be enough to cause a very severe allergic industry and others—to look to see what actually reaction in some people. I think because at the should be on the label and how best it should be moment there is not the scientific evidence to know communicated, and also to ensure that the what threshold level of the allergen is low enough that it is not going to trigger a reaction in people it is information which is then provided for consumers is very diYcult to make those labelling decisions. As I clear and easy to understand. There is such a lot of said, we have work in progress to try to help us set information on the label at the moment and it can Y those levels so hopefully in a few years’ time we will sometimes be di cult for consumers and others to be able to give indicative levels so that if, by analysis, pick out the information they need. It is a really good they show that the risk of cross-contamination is opportunity to take a clear look at what is actually down to a level below a certain management level needed. then that labelling would not need to be added. Miss Fine: If I could add one more thing, about Q411 Baroness Platt of Writtle: When will the new confusing labelling. The Agency does investigate labelling come into force? where there are instances of food being mislabelled Miss Fine: At the moment the discussions are at a and we would issue an alert notice if food was very early stage. We are expecting proposals later this actually mislabelled, for example, if an ingredient year or the beginning of next year so there is still a lot was not properly declared or if there was confusion of scope for having consultation and discussion as to between the ingredients list and the allergy advice what needs to go on the label. I cannot say exactly box, that food would need to be withdrawn. We do when we think it is going to happen, but we are very issue advice on that. committed to make certain there is an improvement in the clarity and usefulness of the label. Q409 Viscount Simon: Mr Bailey, you used the word “regular”, how regular is regular? Mr Bailey: All inspections are based on a risk Q412 Lord Broers: On a similar subject, the Food assessment approach. There is a Food Standards Standards Agency commissioned the 2005 report Agency code of practice directed at enforcement Qualitative Research into the Information Needs of authorities which contains a risk assessment scheme. Teenagers with Food Allergy and Intolerance. One of Basically the more risk a business poses, the more its recommendations for food labelling was “the frequently the business is inspected. Food producing introduction of a universal allergy warning symbol factories producing a large number of individual on the front of packs and a more consistent, clearer items perhaps with a lot of allergenic ingredients approach to the listing of risky ingredients on the would be visited perhaps once every six months or at back of packs”. What progress has been made least annually. A corner shop just selling pre-packed towards implementing this recommendation? allergy: evidence 165
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Mrs Hattersley: We looked at teenagers and early Mrs Hattersley: Yes. twenties because we know that this is one of the groups that is at most risk of having allergic reactions Q414 Lord Broers: The report also suggested the to a food. What we were trying to do was find out development of an allergy chef card which could how best we can communicate information to this be prepared for young people with food allergies age group so that they can manage their condition as a tool to aid communication with catering better. This research was conducted in 2005 and then establishments when eating out. Has this idea been the changes in the statutory legislation came in at the developed? end of that year so there have been improvements on Mrs Hattersley: We have not taken that forward at the information on the back of packs. As Gill the moment. What we have been doing is working mentioned previously the ingredients have to be with all the diVerent stakeholders—the consumers declared with reference to the allergens that they and the caterers and catering suppliers—to try to come from, so that it has to say that casein is from produce guidance on the provision of allergen milk. There is clearer information on the back of the information for foods that are non-prepacked which pack. That legislation also removed a previous are outside the current statutory legislation. At the exemption in the labelling legislation which meant moment we have a draft version of that guidance that if you had a compound ingredient added to a document which we have done a public consultation food previously you did not have to list all the on and we are in the process of reviewing the ingredients within that compound ingredient if it responses to that. We anticipate publishing final made up less than 25 per cent of the whole food. An guidance in the autumn, so that is trying to provide example would be the pepperami slices on top of a better guidance to the industry on how they provide pizza. Previously you did not have to list what was in the allergy information on the non-pre-packed foods. the pepperami—it just said “pepperami” in the We will look as well at how we advise consumers so ingredients list—whereas now you also have to list all that they know what sort of questions to ask when the ingredients within the pepperami. That is clearer they are eating out. Certainly we have provided allergy information for those people who need to leaflets for allergic consumers and for consumers avoid certain foods. The recommendation on the with intolerances which includes a section on when symbols was one of the things that came out from they are eating out and what sort of things they can talking to the teenagers. Superficially it looks like a do (ring the restaurant beforehand, ask whether very easy way of improving labelling but there are a someone can supply food that is free from the lot of practical problems with symbols. Food particular food they are allergic to and how they can manufacturing is very international so it would be ask questions when they are actually in the Y very di cult to introduce symbols in one country restaurant). We are doing work to try to help V because food is manufactured in many di erent consumers and educate consumers on how to manage places and traded. There would need to be very clear their allergy when they are eating out. recognition by the consumers about what the symbols mean. At the moment we have symbols, for Q415 Lord Broers: So these ideas are contained in example, for vegetarian food or gluten free food the Food Standards Agency’s allergy action plan, suitable for coeliacs. There are symbols that can are they? indicate that but we would need to be very clear here. Mrs Hattersley: Yes, there are a number of options we For example, if you had a symbol with a nut on it and are looking at. a line through it, does that mean there are no nuts in the product or would it mean that there are nuts in it so nut allergic people should not eat it? Because of the Q416 Chairman: Could I ask about a situation potential severity of the reactions you would need to which I think is quite specific to coeliac disease in have a very clear and unified system for introducing some ways, and that is to ask why some foods are the symbol. The other practical issue is that at the labelled to say they have gluten or wheat when, moment we have 12 allergens—soon to go up to 14 in according to the European Food Safety Authority, the list—so if we were to have symbols for all those they do not? An example of that is glucose syrup. allergens it starts to make the packaging very Mrs Hattersley: When the legislation came into force complicated again. At the moment we think that it was realised fairly late in the negotiation process clear words on the packaging is the best way forward that there were certain very highly processed food but the whole question of symbols is going to be part ingredients that would no longer contain the of this general EU review so they will look at the allergenic proteins and so what the Commission did usefulness of symbols in certain situations. was ask the industry to submit dossiers on those very highly processed derived ingredients such as glucose Q413 Lord Broers: Is this contained in the EU syrup to justify them being exempted from the considerations? allergen labelling legislation. There is an EU 166 allergy: evidence
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Directive which sets out a list of temporarily exempt that when someone asks them whether there is a derived ingredients so it includes the glucose syrups, particular allergen in a food they are able to give it includes some of the fining agents (there can be accurate information back to the consumer. isinglass or egg or milk proteins used to fine wines or beers) which are also temporarily exempt. That exemption finishes at the end of this year and Q421 Earl of Selborne: If the FSA does not know industry is being asked to submit further information whether this is a problem which is getting better or so that a final list of exemptions can be agreed. We worse, do any other of our advisers here present certainly advise businesses that if they have one of the know whether it is getting better or worse? Is there ingredients that is temporarily exempt that they do any monitoring? not label it because, as you say, that is confusing for Mrs Hattersley: The allergy clinics may record the the consumer and we do not want to over-label when examples where the allergic reactions happen so there there is not actually a risk. may be some information coming from that side of things. Q417 Chairman: Am I right that chewing-gum is also exempt? Q422 Earl of Selborne: You referred to the guidance Mrs Hattersley: Chewing gum is regarded as food so which will be coming out hopefully in the summer if there are allergenic ingredients they would have to which is guidance, as I understand, for the catering be listed.27 establishments; presumably there is also a role in the training programmes. People working in Q418 Lord Colwyn: Is there a third party that checks these establishments get qualifications from the ingredients when it comes from the manufacturers? I environmental health oYcer courses and elsewhere. think probably if I were a food manufacturer I might Is there suYcient training in the module for dealing well put “may contain nuts” on it just to cover myself. with allergies and food intolerance? Does anybody check the claimed allergens? Dr Leitch: I do not think that allergy has a very high Dr Leitch: Normally when enforcement oYcers visit profile in a lot of the training. I think it is mentioned the premises, particularly the manufacturers, they in training documents as something that people in will examine the labelling and they will ask the catering should be aware of but I do not think there manufacturer how he verifies the labelling and is any great exploration of the detail. A lot of that is normally that is done through either sampling and Y analysis or else checking the certificates provided by due to the fact that enforcement o cers themselves the original producer of the products. are on a very steep learning curve.
Q419 Lord Colwyn: So that is a third party sampling. Q423 Earl of Selborne: Would you feel that more Dr Leitch: Yes, that can be third party sampling. The needs to be done in training food operatives? environmental health departments and the trading Dr Leitch: Yes. I think we should try to get it, standards departments have a role to play in that by particularly with the catering colleges where most of testing to assess the truth of what has been said by the the food operatives originate. We need to make sure manufacturer. I think the enforcement side has a very that it is on the training syllabus for them. I also think big role there in not taking things on trust. we need to make sure the enforcement oYcers are well trained so that we can get the cascade eVect Q420 Earl of Selborne: Can I come back to the issues where the oYcers can pass the information on to of catering establishments. Could I ask first of all the trade. about the instance of severe allergic reactions from Mrs Hattersley: In terms of training for the caterers, eating out in catering establishments, is it getting the Agency did ensure that in the training for the better or worse? hospitality sector through the National Occupational Mrs Hattersley: I am not sure if it is getting better or Standards there is an inclusion of food allergy in the worse. We know that this is the more risky situation food safety modules so that people who are being rather than the pre-packed foods. As I said, we have trained in the catering trade do have some awareness been trying to produce guidance for the industry so of allergy and the particular problems. Also the 27 Chewing Gum—There are exemptions from most food labelling Agency produces guidance for the catering trade. In requirements for small packages and this exemption applies to England it is called Safer Food, Better Business and chewing gum. However, if any of the specified allergenic ingredients are used in chewing gum these would have to be there are comparable documents in Scotland and in labelled. The current list of allergenic ingredients doesn’t Northern Ireland. There is an allergen safe method include latex, so there is no requirement for this to be declared, although this list can be amended if an additional allergenic within that so that when they are thinking about food of public health importance becomes apparent. cross-contamination for example of raw meat with allergy: evidence 167
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey cooked meat they can also be thinking about cross- putting the customer in danger. That is one of the contamination of allergen containing foods and non- things that I think needs to be looked at in terms of allergen containing foods.28 training. I did some sampling work a couple of years ago in Northern Ireland to try to buy allergen free Q424 Chairman: I wonder if I could ask you, Dr foods in takeaways because that is where most of the Leitch, to be a bit more specific about how you feel accidents occur. We got a 20 per cent failure rate that training could or should be improved. Are there amongst the foods and we were assured that those some specific initiatives that you have in mind? foods were suitable. We actually looked for a peanut- Dr Leitch: Can I just think about that for a while? free chicken curry but we had a 20 per cent failure rate, yet everybody who sold that said that this is fine, Q425 Chairman: While you do, I just wanted to ask it is suitable for the allergic consumer. They were not whether there are any global initiatives over food aware of cross-contamination issues and they did not labelling. We have spoken a bit about Europe, but we know how the contaminates had got into the food. I do have people travelling all round the world in every think we need to focus much more on that detailed direction. side of things with workshops where these issues can Mrs Hattersley: Codex Alimentarius which was be explored rather than just straight information on mentioned previously does look at labelling and they paper. I can also go on to say that that is my feeling are taking forward an initiative to produce a regarding the enforcement oYcers as well. It is all standard for gluten free foods. That work is on-going very well to have it on paper but whenever you are and there is a further meeting of that committee in asked hard questions during an inspection you really October this year so we are hoping we will actually do need to be much more familiar with the topic and get an agreement on what gluten free should mean you need to drill down into it in detail. which will be helpful. Q427 Chairman: Do I take that to read that you feel Q426 Chairman: Dr Leitch, have we given you that the environmental health oYcers do not have an enough time to think? adequate understanding of food allergy and Dr Leitch: I would say that my perceptions are based anaphylaxis? on what I find as I talk to people in allergen control. Dr Leitch: I think that at the minute they have a I believe that the training needs to be more practically superficial understanding, the sort of thing you based. I think there is training, as Sue said, where would get from reading a leaflet. I think that they documents are given to the businesses, the documents need a much more detailed understanding. I think we contain a section on allergen control—a short are going to cover that in the final question. section—and every business should have that. However, in terms of looking at that from a practical Q428 Chairman: Should we just go straight into view point I believe we need much more training from that now? a workshop perspective so that people can explore Dr Leitch: Certainly, yes. the issues dealing with the allergens, where the allergens are found, what foods they may be hidden Q429 Chairman: Would you like to go straight into in. Issues like dealing with the customers as well. The that question over the environmental oYcers per se? biggest problem for someone with a food allergy is Dr Leitch: I was involved in 2005 with the Food asking someone in the trade, “Is this food suitable for Standards Agency drawing up training materials for me?” Those issues need to be brought home in much enforcement oYcers. I am now on secondment to more detail to the catering trade so that the catering Safefood and to the EU body CAWT to take that a trade do not give the wrong answer. One of the stage further. We are involved in training workshops situations with the catering trade is that for during the summer and we are bringing in the generations they have been taught that the customer enforcement oYcers now. It is all environmental is always right and they try to be helpful and very health oYcers because it is only environmental health often when they are trying to be helpful they are oYcers who are involved in food control in Northern 28 Enforcement OYcer Training—In relation to training for and Southern Ireland; the trading standards oYcers enforcement oYcers, we described the training that the Agency is developing. However, you should also be aware that there are do not have any food involvement there and certainly many commercial organisations currently providing training we see the workshops as a very, very important tool for Environmental Health OYcers and Trading Standards that would bridge the gap between the book-based OYcers, including the Chartered Institute for Environmental Health (CIEH). The courses that they provide on food safety knowledge and the trade. I know in the UK that Sue could be extended to include food allergy and intolerance and and colleagues are running pilot training for we are aware that there is a joint initiative between the Food environmental health oYcers which I think is very, Standards Agency Wales and CIEH Wales to raise awareness both of food allergy and intolerance issues with Welsh very good. My only comment would be that that enforcement oYcers. training should be rolled out across all environmental 168 allergy: evidence
31 January 2007 Mrs Sue Hattersley, Miss Gill Fine, Ms Andrea Martinez-Inchausti, Dr Ian Leitch and Mr Les Bailey health departments as soon as possible and with has been working with the British Dietetic trading standards colleagues as well because trading Association to ensure that there is information on standards are very heavily involved in the food both food intolerance and food allergy to help people labelling aspects that we talked about earlier, making understand the nature of the condition but also how sure that the right labels are on the right products. I to take action to manage their condition and to avoid think that is very important as well. triggering a reaction. It is important that it is put into Mr Bailey: The allergen training courses are being context, that people know where to go to get accurate rolled out across the UK and they will be attended by help to manage their condition. I also want to add environmental health oYcers and trading standards that in terms of information when foods are oYcers. The take-up from our oYcers has been very improperly labelled for whatever reason, Sue good. mentioned withdrawal notices. This information can go into food stores, and will probably be put into a Q430 Lord Colwyn: Most people who have an press release, or information could be put into allergy problem carry an EpiPen or something like newspapers. We are very conscious that although this that. Do you think the time will come when catering is very helpful it is perhaps not as immediate as it establishments or restaurants, as part of their licence, might need to be. We are therefore exploring other might have to show that they have somebody on the options and are about to introduce an SMS texting staV who knows how to deal with allergies and they initiative. People can subscribe to this (those who do have to have an EpiPen? I have to say that it is only need to know when there is a problem with a label), about a year ago since the EpiPens in this building and they can get immediate information about that. were locked up at 5.30 and nobody could get hold I think it is about raising awareness and providing of them. practical help for individuals. Dr Leitch: I think it would be very useful in terms of their defence if anything went wrong because to show Q431 Lord Rea: In the training of environmental due diligence they need to show that they have health oYcers do you feel that there are suYcient assessed hazards and that they can control hazards. It is my belief that allergens are a hazard that you deal trainers of adequate calibre who have a detailed with in just the same way as any other hazard. As knowledge of allergies and problems associated with with food poisoning bacteria you should deal with it to go round? the allergen hazard in just the same way. You need to Dr Leitch: I do not think there are. I think it is a consider the hazard and you need to put the controls specialised area and it is important that you do not into place. I would like to see a position where when have people giving out the wrong information. That environmental health oYcers are carrying out their is certainly an area of concern. inspections that allergens are assessed in the same way as any other hazard. Q432 Lord Rea: Where are they recruited from? Mrs Hattersley: If I could just add about the training Who are we talking about when we talk about courses that we are rolling out, we are running 10 training people in allergy control? courses across diVerent areas of England from Dr Leitch: I do some training. There are very few January through to March. There will also be some people who have completed any detailed training. courses in Scotland and in Northern Ireland. These There is a lady in the public gallery, Hazel, who has courses are being held in diVerent areas but there are people from a number of local authorities coming to done an awful lot to raise allergy awareness and each of these courses. When we advertised for these Hazel would be a trainer and I know Hazel has 10 we had at least 30 local authorities wanting to host trained one other person. There are very few people these events so we will be rolling out more later on in with the detailed knowledge and training and that is the next financial year. perhaps another concern. Miss Fine: Could I just add a point about the Mrs Hattersley: The Agency does provide its own increased awareness that you were talking about, I training for environmental health oYcers and trading think it is absolutely fundamental that there is much standards oYcers. This is the work that we are rolling more awareness across all the diVerent groups, not out. That was the first step of what we are doing. just the caterers but also the enforcers and What we want to do once we have those courses up consumers. One thing we have not touched on is the and running is to then talk to the general training importance of working together to ensure that there providers, including perhaps the undergraduate is accurate information for consumers and to help syllabuses for environmental health oYcers so that people to be more aware of the issues (not just the we can start to introduce allergy at a very early stage individual but also their families and their carers, of training. That is certainly something we want to which is where there is also a concern). The Agency look at in the coming year. allergy: evidence 169
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Dr Leitch: I agree absolutely with that and I believe very much for having come today, for your very clear that that information will give training on a general answers which have informed the Committee. If there level but it will be crowding into the syllabus with is anything else that you would like to give us everything else that an undergraduate does. I believe information on, please feel free to write in after this there is certainly room for specialist training in that session and it will be considered along with your oral area. evidence. You will be sent a copy of the transcript to Chairman: Do any of our other witnesses have correct for accuracy. Thank you. anything else that you would like to inform us today in relation to questions? No. Then can I thank you
Supplementary memorandum by the Food Standards Agency The Food Standards Agency has had a commitment to address the needs of food allergic and food intolerant people and their families since it was established in 2000. This is reflected in the high level objective in our revised Strategic Plan for 2005–10, which will be published shortly: “To develop appropriate policies and standards to help ensure safety and choice for food allergic and food intolerant consumers”. The Agency is meeting this commitment in three ways—by improving food labelling (both statutory and voluntary), by raising awareness of food allergy and intolerance with food businesses, enforcement bodies and consumers, and by commissioning research to develop the evidence base and improve knowledge and understanding of the mechanisms involved. The Agency has been instrumental in delivering a number of key improvements: — The Agency negotiates on behalf of the UK on EU legislation and there has been a significant improvement in the statutory requirements regarding the declaration of allergenic food ingredients in pre-packed foods, leading to more accurate and informative labelling. — The Agency is working with a European consortium which is investigating how best to determine management threshold levels for allergens in food products. This will provide a basis for helping the food industry manage allergens during food production, in particular their decisions on whether or not to use advisory labelling. — The Agency works in partnership with food manufacturers, retailers, allergy and intolerance support organisations and enforcement bodies to produce best practice guidance on areas outside the scope of these statutory requirements. In July 2006 the Agency published best practice guidance on the management of allergen cross contamination and advisory labelling (such as “May Contain nuts”). — The Agency is currently working with stakeholders to produce best practice guidance on the provision of allergen information for foods that are not pre-packed, such as foods sold in catering. Draft guidance was the subject of a public consultation last year and the final version will be published in 2007. — In response to requests from enforcement oYcers, the Agency has recently developed a training course on allergen management to raise their awareness of allergy concerns and help them advise the businesses they visit. — The Agency funds a significant research programme (around £1m per annum) to investigate possible causes of food allergy and the mechanisms involved in the development of either allergy or tolerance to food proteins. This programme has looked at the role of early life exposure to allergens during pregnancy and breastfeeding in the development of allergy or tolerance to food allergens. A key finding of the research is an improved understanding that early, low level environmental exposure to allergens (such as via dermal exposure if the food is eaten by other members of the household) may also be a route of sensitisation to food allergens. The Agency is currently considering further research proposals on the role of the weaning diet in the development of allergy or tolerance. — The Agency provides a range of information for consumers via our website (www.eatwell.gov.uk) and through leaflets that we have developed in partnership with the British Dietetic Association, to help people successfully avoid the foods to which they react. 170 allergy: evidence
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The Agency places a great emphasis on working partnerships with all stakeholders as this provides real benefits in raising awareness and improving understanding in this complex area. This has led to real improvements for allergic and intolerant consumers, while at the same time ensuring that any guidance produced is both practical and not unnecessarily burdensome for food businesses. 31 January 2007
Further supplementary letter from the Food Standards Agency There are a few points I should like to clarify:
Chewing Gum Thre are exemptions from most food labelling requirements for small packages and this exemption applies to chewing gum. However, if any of the specific allergenic ingredients are used in chewing gum these would have to be labelled. The current list of allergenic ingredients doesn’t include latex, so there is not requirement for this to be declared, although this list can be amended if an additional allergenic food of public health importance becomes apparent.
Enforcement Officer Training In relation to training for enforcement oYers, we described the training that the Agency is developing. However, you should also be aware that there are many comercial organisations currently providing training for Environmental Health OYcers and Trading Standards OYcers, including the Chartered Institute for Environmental Health (CIEH). The courses that they provide on food safety could be extended to include food allergy and intollerance and we are aware that there is a joint initiative between the Food Standards Agency Wales and CIEH Wales to raise awareness both of food allergy and intolerance issues with Welsh enforcement oYcers.
Guidance on Allergen MAnagement and Consumer Information (“May Contain”Labels) We should also alike to clarify that this guidane was produced by the Food Standards Agency, working in collaboration with stakeholders, including the Food and Drink Federation and the British Retail Consortium. We are grateful to them for producing the first draft of the document, which was based on their own previous guidance. 20 February 2007
Memorandum by The Anaphylaxis Campaign
Introduction and Summary
The Anaphylaxis Campaign 1. The Anaphylaxis Campaign is a national patient support organisation representing people who are at risk from severe allergic reactions including the most extreme form, anaphylaxis. 2. During anaphylaxis the whole body is aVected. Symptoms include swelling in the throat and mouth, severe asthma, a dramatic fall in blood pressure and collapse and unconsciousness. Extreme cases can be fatal. Causes include foods (notably peanuts, tree nuts, milk, eggs, shellfish and fish); certain drugs; insect stings; and natural rubber (latex). 3. The Anaphylaxis Campaign is a registered charity (No 1085527) set up in 1994 to raise public awareness of severe allergic conditions, inform and educate those aVected, and maintain dialogue with the Government, food industry and health professionals. Main sources of income are membership subscriptions and donations, fundraising by volunteers and corporate grants. allergy: evidence 171
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Our submission 4. Our submission will seek to demonstrate that allergic disease impacts severely on the quality of life of those aVected and that currently the lack of NHS provision has a serious eVect on those living with the condition both in terms of medical support and day-to-day living. Some of our evidence is supported by the evidence of research, and we also draw on 13 years’ experience of running a helpline, workshops, support groups and member anecdotes. We see much anxiety and serious impairment of quality of life. 5. Most of the facts, quotes and experiences highlighted in our submissions feature people whose allergy trigger is food. This is because the membership of the Anaphylaxis Campaign (7,904 people in October 2006) is made up primarily of people with food allergy problems. But we acknowledge that the other causes of anaphylaxis are also important, resulting in a significant impairment of quality of life. 6. Peanuts and tree nuts figure prominently in our evidence because allergies to these foods are the ones that most commonly cause fatal and life-threatening reactions. A recent study showed that the incidence of peanut allergy has tripled in the last decade and now aVects one in 70 children across the UK.
Allergy and intolerance: important differences 7. The function of the immune system is to prevent harm to the body. It normally does this by fighting oV invaders but in people who are prone to allergy, the immune system mistakenly registers harmless foods or substances as a threat. A person with an allergy produces allergic antibodies to a particular food or substance (known as an allergen). Contact with the allergen causes chemicals including histamine to be released from cells in the blood and tissues. These act on diVerent parts of the body to cause symptoms such as swelling, skin rash, streaming eyes and nose, vomiting, breathing diYculties or asthma. For a few people, these symptoms may be extreme and aVect the whole body (anaphylaxis). 8. Food intolerance is diVerent. It is not triggered by the immune system, it cannot be diagnosed by standard allergy testing and must be treated diVerent to allergy. Unfortunately many people who experience symptoms that seem to be connected to food—such as nausea, sickness, headaches, digestive diYculties or sluggishness— mistake this for allergy, when in fact it may be a form of intolerance. Furthermore, there are many people who believe themselves to be allergic or intolerant who in fact have some other underlying medical problem. All of these people—whether genuinely allergic, intolerant, or aVected by some other disease—find it extremely diYcult to access accurate information and obtain expert attention because of the lack of allergy services. This problem needs to be addressed urgently.
Contents 9. Because our work covers a variety of aspects of living with severe allergy, we have included evidence on: the following subjects: — Food labelling and eating out. — Allergy in schools. — Self-treatment of allergy and the dangers of alternative therapies. — Impact of allergy and quality of life. — Conclusion and future work.
REFERENCES [not printed]
Food Labelling and Eating Out
The nature of the problem 1. This paper will demonstrate that people with severe food allergy face a genuine risk, not a hypothetical one, and that urgent steps need to be taken to address this. People seeking to avoid a particular food, or foods, encounter numerous barriers. Despite improvements provided by new European legislation, food labelling is frequently inconsistent and confusing. The explosion in “may contain” labelling—adopted by food companies to signal the small possibility of allergen traces—fuels this confusion. 172 allergy: evidence
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2. Eating out poses an even higher risk because of the complexities of food production in catering establishments, lack of knowledge among catering staV, food enforcement oYcers and allergic consumers alike, and the fact that allergic consumers do not have the benefit of an ingredient list to guide them.
Defensive labelling 3. The Anaphylaxis Campaign has overwhelming evidence that allergic consumers have become increasingly angry and frustrated with restriction in their choice of foods, caused by the escalation in defensive labelling (eg “may contain nuts”). Food companies use this method of labelling to signify that a food product may have been subject to cross-contamination in the food production chain. This is not regulated by law, and there is little consistency across the industry in how warnings are presented on food packets. The confusion consumers face puts them at serious risk. Almost all of the young people attending Anaphylaxis Campaign educational workshops for allergic teenagers say that they disregard “may contain” warnings because they believe food companies are simply “covering their backs” and that the hazard is not genuine. This is dangerous behaviour. Allergen testing laboratories have demonstrated that allergen contamination is a real risk. 4. A “shopping survey” undertaken by the Anaphylaxis Campaign for the Food Standards Agency found that “may contain nuts” warnings appeared on a significant proportion of foods that do not have nuts as ingredients. They appeared on 69 per cent of cereals, 58 per cent of biscuits and 56 per cent of confectionery. The way these warnings were displayed meant that often shoppers could not find or read them easily. Warnings were found some distance from the ingredient list, in tiny, unreadable type, in coloured type on coloured paper and sometimes under a flap. 5. A membership survey undertaken by the Campaign drew many hostile comments, of which this one is typical: “I had always thought that food labelling was there to help and protect the consumer. But now I wonder if it really exists to protect the food industry.” 6. The Food Standards Agency has gone some way to address consumer concerns with its voluntary guidance produced in 2006. This is useful guidance and may help to bring about some consistency and better quality of “may contain” labelling. 7. However, it is insuYcient on its own. Thanks to a grant from the Agency, the Anaphylaxis Campaign is developing the UK’s first certification programme to enable food companies to ensure optimum allergen control. This is currently the subject of a wide consultation exercise and the Anaphylaxis Campaign plans to launch the programme in 2007. 8. This certification programme invites the participation of the food industry on a voluntary basis. The question remains as to whether “may contain” labelling should be regulated by law. This requires much serious debate. Legislation takes many years to produce and action is needed now. Many food companies, particularly but not exclusively the larger ones, already follow good practice and we must wait to see whether the measures described here have any eVect.
Allergy and catering establishments 9. The risks increase significantly when people eat out, largely because consumers do not have the benefit of comprehensive food labelling and must often rely on verbal assurances of catering staV. Every year, a minimum of six to seven deaths from food-induced anaphylaxis are reported. The true figure is almost certainly higher because of misdiagnosis or misreporting. Reports from the US and the UK confirm that the greatest risk for allergic consumers comes from complex foods prepared by restaurants and other catering establishments. 10. The following fatalities are just a small proportion taken from the Anaphylaxis Campaign’s register of allergy-related deaths. 11. Example one: A young Lancashire woman died after eating a curry that contained peanut. She had asked for a peanut-free meal. The environmental health oYcer investigating the case concluded that she died because of “a communication problem.” 12. Example two: A promising young athlete, who was allergic to nuts, died after eating a Coronation chicken sandwich which, unknown to him, contained nuts as an intended ingredient. 13. Example three: A Liverpool girl with a nut allergy collapsed and died during a formal dinner at university after she ate a dessert that, unknown to her, contained nuts as an intended ingredient. allergy: evidence 173
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14. Studies of allergy-related deaths have been undertaken thanks to an association between the Anaphylaxis Campaign and Dr Richard Pumphrey, of the North West Region Immunology Service. Our register of fatalities draws clear conclusions about the circumstances under which people with food allergies usually die. The intention is to learn lessons and save lives. 15. Three-quarters of the reported deaths occurred when food was bought in catering establishments, such as restaurants, hotels and takeaways. 16. In some cases where the victim had asked for a meal without nuts, the person serving (and in several cases even the caterer) had not been aware that the food contained nuts. In other cases, the request for nut-free food had either been misunderstood or forgotten. 17. Most cases involved the allergen being present as an intended ingredient, but unexpected or unrecognised by the food business, the consumer, or both. 18. In 22 cases out of 54 that were studied in some depth and published in the medical literature, the patient had never been prescribed emergency adrenaline. In some cases, adrenaline had been prescribed but was not being carried on the day of the fatal reaction. What was lacking here was patient education. 19. Despite a growing awareness of food allergy, deaths are still occurring. Important lessons are not being learned. The Anaphylaxis Campaign is aware of a much larger number of near-fatal reactions, where the victim was resuscitated thanks to prompt medical treatment. These cases do not make headlines. The Royal College of Physicians reported that hospital admissions due to anaphylaxis increased seven-fold in a decade. 20. In June 1999, before the Food Standards Agency was established, Mr Edward Davey, MP for Kingston and Surbiton, responded to the death of the young athlete Ross Baillie by telling the House of Commons: “When a fit, gifted athlete like him dies because of a few bites of a chicken sandwich, it is surely our duty to ask whether or not his death or deaths like it could have been avoided. We need to ask whether or not actions this house has the power to take could help prevent such tragedies in the future.” 21. In response, Food Safety Minister Mr JeV Rooker said that one answer might be “an eVective code of practice which will raise awareness, so that the industry takes responsibility.” He pledged to “take this issue forward” to see whether a code of practice would be “beneficial”. 22. The Food Standards Agency has recently made some progress towards addressing the needs of food- allergic consumers who wish to eat out. Draft guidance for the catering industry on management of allergens and communication of information is out for consultation. This is welcome, but it is voluntary guidance only and will only partially address the problem of allergy risks in catering situations. 23. We believe that the long-term solution to addressing the problem of food allergy in the catering sector lies in compulsory training programmes in allergy for food enforcement oYcers, particularly EHOs involved in the assessment of food safety management systems. They could then ensure better compliance and a more consistent approach to food allergen management by food businesses. In our view, this should be the Agency’s main objective. 24. Environmental health oYcers are the guardians of food safety in the UK. OYcers are in regular contact with all catering establishments, seeking to ensure the safety of the food supplied. No other agency is involved in the regular assessment of food safety management systems. In many instances, particularly in the smaller businesses where self-regulation is not strong, the advice of the oYcer is taken as the law and work is carried out at their request so it is vitally important that these oYcers view allergen control as an integral part of the food safety inspection regime and that they ask the correct questions. Many oYcers may agree that allergen control is important but may not consider them during inspections. 25. A survey carried out among environmental health oYcers involved in food safety enforcement work in Northern Ireland in 2000 revealed that less than 20 per cent (6/37) of the oYcers considered serious food allergens (nuts/peanuts) when carrying out assessment of the premises’ food safety management system. Of the 31 who did not, 26 considered that they lacked knowledge and training in the subject of food allergen control. In 2002 another survey revealed that little had changed and 100 per cent (35/35) of the oYcers surveyed felt that they needed training in the area of food allergen control. Several oYcers expressed the view that training should integrate allergy into the HACCP food safety management system, perhaps because food safety management is the bedrock of the inspection process. 26. We conclude that training in food allergy must become a priority for local authority food enforcement oYcers. They must be given formal accredited allergen control training, and all guidance on food standards and safety/hygiene must reflect the need to consider allergens as part of the formal inspection process. 174 allergy: evidence
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REFERENCES [not printed]
Allergy in schools 1. As stated in our introduction and summary, the incidence of peanut allergy has tripled in the last decade and now aVects one in 70 children across the UK. It is estimated that 250,000 children are allergic to peanuts, tree nuts or both. Allergies to other foods (such as kiwi fruit) also appear to be on the increase. 2. Given this relatively high prevalence, it is probable that every school has at least one pupil who is severely food-allergic and it is unsurprising that there are often tensions in schools. Parents may make unrealistic demands (such as a total ban on the allergenic food), schools may be driven by fear to respond unhelpfully, and the result in all cases is that the child suVers. This is certainly the experience of the Anaphylaxis Campaign helpline staV. 3. The Anaphylaxis Campaign believes strongly that the risks faced by allergic schoolchildren can be managed and minimised. It is our experience that ignorance lies at the root of schools’ inability to cope. What they need is help, information, support and training. 4. A questionnaire study within the Severn NHS area of south west England found that schools are not suYciently well-informed about management of acute allergic reactions. Forty-four per cent of the schools with an allergic pupil either did not have staV trained to administer medication or declined to respond to the questionnaire. Less than half of the schools with nut-allergic children said they gave information to all the teachers about this medical condition. 5. An audit of schools in the Nottingham area identified inconsistency in knowledge and awareness about treatment of allergic children. Gaps in training for both school nurses and school staV were identified, particularly for midday supervisors. 6. A study published in the British Medical Journal said that patients and GPs lack knowledge on when and how to use adrenaline auto-injectors. We conclude that if GPs lack knowledge, it should come as no surprise that there is ignorance in other sections of the medical community. 7. A questionnaire survey of 14 school nurses in the West Midlands, undertaken by the Anaphylaxis Campaign, showed that all the nurses surveyed would undertake training by the Campaign, if it was available, and 8/14 acknowledged that they required additional help and information (eg to ensure their knowledge is up to date). The West Midlands is an area where allergy awareness in schools is already relatively high, indicating that training is probably more urgent in other areas. 8. A 2006 study showed that most Scottish schools now have at least one child at risk of developing anaphylaxis within the school setting, and although most of these schools have trained staV with access to emergency medication and personalised care plans for these children, they continue to express concern about their ability to respond eVectively in an emergency situation. 9. Some progress has been made. The Department for Education and Skills acknowledges that anaphylaxis presents a significant challenge for schools and produced a useful guidance document for schools. In 2004 the Anaphylaxis Campaign received grants from the Peanut Foundation and the American Peanut Council to set up a website specifically aimed at providing allergy-related information to schools. This website received 4,029 visits during the first month it was launched. The number of visits varies month by month between just under 2,000 to just over 4,000 and these levels are being maintained. 10. However, schools have needs that cannot be met by a website. School staV now have access to information but they also need active, personal instruction on how to recognise symptoms, how to treat them with injectable adrenaline and how to manage allergies on a day-to-day basis. In many schools, the key people who ensure that school staV are properly trained are the school nurses. They too need active, personal instruction. At present, the knowledge they possess varies in content and quality around the country. There is inconsistency and, in some cases, a dangerous ignorance of the facts. 11. The Anaphylaxis Campaign believes that the training of school nurses should fall under the Government’s remit, but in the absence of any Government training, the Campaign is now planning to set up a national training programme of its own. This was piloted in five areas of the UK in early 2006, and will be rolled out nationally in 2007–08. 12. The national roll-out depends on funding becoming available and therefore its success is by no means assured. Patient organisations like the Anaphylaxis Campaign live a precarious existence; vital educational and training programmes can only succeed with Government and/or corporate support. allergy: evidence 175
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13. Some corporate sponsors for this schools training programme have been identified, but others are urgently needed. Without high-quality training, of the kind that is proposed, children will continue to be at risk. 14. These risks may increase as a result of Government recommendations that form part of its “Transforming School Food” initiative. Whilst the Anaphylaxis Campaign supports the general principles of healthy diets for children, we are concerned with the Government’s comments that snacks sold in school vending machines and tuck shops may include nuts and seeds. 15. This recommendation raises the possibility that peanuts, tree nuts and seeds will become commonly eaten snacks in many schools. It raises the further possibility that allergic reactions will increase. 16. Primarily this is a cross-contamination issue. Proteins from nuts are notoriously diYcult to clean and tend to become transferred easily from hands to surfaces such as tables, chairs and computer keyboards. There is a real risk that these allergenic proteins will be picked up on the hands of allergic children. “Casual contact” reactions caused by touch are rarely thought to be life-threatening, but they can lead to moderately severe symptoms requiring treatment—particularly if the child touches his or her mouth. 17. Evidence for this came in a paper published by a German medical team. They reported the case of a 32-year-old man with peanut allergy who suVered a serious allergic reaction during a card game. It transpired that his friends had been eating peanuts. Although they kept them well out of his way, peanut protein from their fingers found its way on to the playing cards. As the cards often stuck together, the player with the allergy licked his thumb to separate them. After one hour he felt swelling of lips and tongue as well as shortness of breath. He received emergency medical treatment. 18. The Anaphylaxis Campaign fears that if schools follow the Government recommendations in this respect, we will see an increase in allergic reactions in schools. At the very least, it will cause great anxiety for the families of allergic children, many of whom are unclear about the actual risks caused by “casual contact” with food allergens. 19. The Anaphylaxis Campaign has launched a series of monitoring exercises that will seek to find out whether the prevalence of nuts is actually increasing in schools and whether this is causing problems. 20. We feel the House of Lords Select Committee should be aware of this issue because it demonstrates that: — The Government’s “Transforming School Food” initiative appears to have taken little account of food allergies. — Research is needed to determine actual risk levels that people with food allergies face. There is still much debate about the degree of risk posed by “casual contact” but it causes extreme distress among the families aVected.
REFERENCES [not printed]
Self-treatment of allergy and the dangers of alternative therapies 1. When avoidance fails, as it does for almost everyone with food allergy, the symptoms may be mild or they may be life-threatening. Mild symptoms are treated with oral antihistamines, obtained on prescription or over the counter. Serious symptoms constitute a medical emergency and require an immediate injection of adrenaline. Allergy doctors recommend that prescribed adrenaline treatment kits (EpiPen or Anapen) are available for those at risk. 2. Unfortunately there is a lack of consensus in the medical community over who should be prescribed adrenaline, how many treatment kits should be available, and at what stage of a reaction adrenaline should be administered. 3. Macdougall et al suggested that for children, the risk of a fatal reaction is exceedingly small and concluded that adrenaline injectors are over-prescribed. 4. Many other experts argue that carrying adrenaline saves lives. Hourihane argues that adrenaline provides an assurance to patients, parents and child carers alike that they are not powerless; they have a means to protect themselves. 5. This lack of consensus leaves general practitioners and others in primary care in a quandary: they seek guidance from experts but find the experts disagreeing among themselves. 6. The Drug and Therapeutics Bulletin provided sensible guidelines for those caring for severely allergic children but acknowledged there was a lack of reliable data on which to base decisions. 176 allergy: evidence
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7. The Anaphylaxis Campaign advocates the setting up of national consensus guidelines for the management of severe allergy and the prescribing and administration of adrenaline. 8. This current lack of consensus guidelines leads to confusion among medical professionals patients alike. At the root of the problem is the poor quality of Britain’s allergy services. Because reliable information from the NHS is so scarce, patients turn to other sources. Some of these are unreliable and inaccurate. 9. People may rely on information they see in the media, which is frequently misleading and sometimes dangerous. Such headlines as “60,000 kids at risk from peanuts” (Daily Mirror) are a serious overstatement in terms of the actual numbers of children whose lives are threatened. The internet may also be a tempting source of information but many websites provide information that is either inaccurate, confusing, out of date, unnecessarily alarming, written in terms lay people cannot understand, or promoting questionable allergy tests and treatments. There is also a temptation for patients to consult alternative practitioners, with the inevitable risk of misdiagnosis and inappropriate treatment. 10. A 2006 study found that a wide range of allergy tests are available from the internet, with about one-third being reputable tests but the rest of unproven value. The authors say that few websites oVering these tests acknowledge the need for careful interpretation. 11. The Anaphylaxis Campaign helpline staV are aware that people with allergies will frequently seek and locate sources of help and information that may well be of dubious value. Often they have waited many months for an NHS referral and are desperate for answers. The types of testing considered include Vega, kinesiology, and hair and blood testing conducted by mail. Some of these testing methods are promoted in High Street health food shops. In addition, “cures” are oVered by many practitioners including Chinese herbalists, oriental “massage” practitioners and others. Many of these methods have no proven value at this time. 12. During one Anaphylaxis Campaign support group in South London, a young woman with severe food allergy was advocating the use of “freedom technique”, a therapy whereby the patient, at the onset of a reaction, taps their index finger under the nose and above the top lip. She claimed this stopped an anaphylactic shock occurring and that she does it before taking adrenaline. The meeting was made up of (in our opinion) intelligent middle class women, most of whom were seeing a good allergy specialist in London, yet at least 50 per cent wanted more info and appeared to be considering this as a technique to try. 13. The situation we have described will continue. To summarise: There is a great need for an improvement in allergy services under the NHS; and there is a great need for national consensus guidelines for the management of severe allergy and the prescribing and administration of adrenaline.
REFERENCES [not printed]
Impact of Allergy and Quality of Life 1. There is no cure for food allergy. People at risk must adopt avoidance as the first line of defence. They must commit themselves to learning management strategies, reading food labels scrupulously every time they shop and taking strict precautionary measures when eating out. Unfortunately these defensive measures frequently fail. Many of those aVected describe food allergy as “a sword of Damocles” and perceive mealtimes to be akin to “playing Russian roulette”. 2. The risk they face is real, not theoretical. The following example is one of thousands reported to the Anaphylaxis Campaign during its 13-year history: A teenage boy ate two mouthfuls of apple pie bought in a supermarket. He suVered anaphylaxis requiring emergency medical treatment. The pie contained 0.006 per cent milk protein, quite legally undeclared (at that time). 3. Incidents like that are relatively common and lead to extreme anxiety and poor quality of life among the families aVected. The Anaphylaxis Campaign helpline received 6,269 calls during 2005. Many of the callers showed themselves to be extremely fearful because of the unpredictable nature of severe allergy. Many of their fears are unfounded and result from common myths that give a disproportionate impression of risk (a process that is fuelled by media scaremongering). One of the common myths is that a severely allergic child is unlikely to reach adulthood. 4. The way to dispel those myths is better patient education and more research that clearly puts risks into perspective, as well as research that oVers patients better treatments. allergy: evidence 177
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5. The anxiety linked with peanut allergy was quantified by a research study showing that children with the condition are more anxious than children with insulin-dependent diabetes mellitus. Children from both groups completed “quality of life” questionnaires and recorded with a camera how their condition aVected their lives over a 24-hour period. The results were then analysed.
6. In comparing the two groups, the researchers found that children with peanut allergy were more afraid of potential hazards, more anxious about eating and felt more restricted regarding physical activities. The researchers believe this anxiety may stem from the feeling that they have little control over their lives. The team’s report said this high state of anxiety among allergic children was unjustified and did not have to be permanent. With appropriate education about allergy management, children could be helped to develop self- confidence and a positive attitude.
7. In 2005 and early 2006 the Anaphylaxis Campaign undertook two surveys of its own members.
8. The first survey was conducted during November and December 2005. All 7,695 members were sent a letter asking them to write about their experiences of living with severe allergy. Of the 7,695 who were mailed, 1,021 replied—making a 13 per cent return. This is a very high return for public surveys.
9. One parent who responded told of a long wait to have her son properly diagnosed “When William had a severe reaction to peanuts we had to wait nine months before we could have him allergy tested.” Others were happy with the service but worried that the medical profession was over-stretched: “StaV fantastic, from GP to specialist, but definitely a feeling that they felt overwhelmed.”
10. A great many of those who responded said they were disillusioned by the NHS: “We have had to fight for medical assistance and still feel unsupported.” Some said they had been forced to go private: “The waiting time for a hospital appointment for testing was at least six months. We paid to go privately.” Many more were grateful that they managed to see a specialist but were concerned at the distance they had to travel to take up these appointments: “We recently went to our GP in Maidenhead who stated we would have to go to Southampton for any specialist treatment. This will be a round trip of 150 miles plus.”
11. One respondent recounted a dangerous piece of advice given by her GP after her son presented with allergic symptoms: “The GP said he had no training in allergies and a slow reintroduction of nut traces may be the way to go.” Another felt let down by the GP in the day-to-day management of allergy: “We have been oVered very little help or information about his allergy from our GP or local hospital. We have gained nearly all our knowledge of his allergy from the Anaphylaxis Campaign.” Another parent said: “The GPs and nurses at our practice had no advice for us, other than do not give her peanuts.”
12. Experiences such as those quoted above are among the causes of extreme anxiety and poor quality of life experienced by people aVected by anaphylaxis. Responding to our survey, one mother said her anxiety is so great she only manages it by having her grown up allergic son call her daily. Another spoke about her disabled son and stated “My son aged 10 has severe disabilities but the thing that most prevents us from leading an ordinary life is his severe nut allergy.”
13. A second, more formal survey took place in January 2006 to provide quantitative information. This time the membership was asked to complete an on-line questionnaire and this brought responses from a total of 1,117 members (patients or the carers of patients). This amounted to 14 per cent of the membership. The objective was to find out about the experiences of allergy services through the NHS as well as how living with allergy aVects the quality of life.
14. Quality of life is a huge issue as our findings show. The people who responded have the benefit of the support and information of the Anaphylaxis Campaign, yet even they are profoundly aVected.
15. Full results of both surveys are presented with the hard copies of this submission.
16. To summarise: The Anaphylaxis Campaign wishes to see: Better patient education for people at risk of severe allergies in order to improve their quality of life; more research that clearly puts risks into perspective; new and better forms of diagnosis and treatment. 178 allergy: evidence
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REFERENCE [not printed]
Conclusions and Future Work
Government policies to date 1. We consider that the measures proposed in the Department of Health’s Review of Services for Allergy will fail to address a serious unmet need. It appears that the Department of Health has scant regard for the whole discipline of allergy as evidenced by the lack of any emphatic recommendations about the development of allergy services, despite all the evidence presented. We support the measures detailed in the Royal College of Physicians Report and believe that these are the answer to the significant problem of poor allergy services. 2. We call on the Department of Health to reconsider its recommendations in its recent review of allergy services in light of those made by the House of Commons Select Committee for Health in November 2004. They recommended 40 new specialist posts in the field of allergy which would greatly reduce the burden currently placed on the 27 whole time equivalent specialists and eight trainees who are working in the field at present. Once trained, these doctors will join the allergists currently at work in the NHS to become the core of a modern allergy service which can be available to patients across the whole country when they need it. Subsequently the more trained specialists there are the more trainees can be recruited, meaning a constant supply to replace those who leave the discipline for whatever reason. 3. On the other hand, the Food Standards Agency has made great progress towards addressing the needs of food-allergic consumers. We have worked with the Agency’s allergy branch since the Agency’s inception and are impressed with the strong grasp they have of the issues. Indeed, there have been many useful measures taken by the Agency, including guidance documents for caterers, food manufacturers, retailers and the allergic public, and the funding of individual projects undertaken by the Anaphylaxis Campaign. Furthermore, the Agency’s research programme is funding some vital work, and the Anaphylaxis Campaign hopes fervently that this funding will continue. Ultimately it is in research that the hopes of people with allergies lie. We outline in Point 7 below some the areas where, in our opinion, progress is needed. 4. Despite much progress, people are still dying of allergies. Further work in the catering sector—where most of the serious reactions occur—is vital. What is needed is a full national training programme for local authority enforcement oYcers. This is lacking at present. 5. On the subject of schools, we feel the House of Lords Select Committee should note that the Government’s “Transforming School Food” initiative appears to have taken little account of food allergies. 6. There is a great need for national consensus guidelines for the management of severe allergy and the prescribing and administration of adrenaline.
The need for future research 7. The Anaphylaxis Campaign would like to propose a number of areas for research. These have been compiled during discussions involving experienced staV members of the Anaphylaxis Campaign—“front line” people with regular direct contact with people with allergies. — “May contain” labelling: How often do reactions occur through people eating food labelled “may contain X”? What symptoms do they experience? What foods are they reacting to? — Food production: What are the threshold levels for individual food allergens (the amount of allergen below which a reaction will not occur)? What food production procedures and cleaning methods would be adequate to bring food to beneath this safety line? — Allergy care: Which patients should be prescribed adrenaline auto-injectors and which patients should be denied them? How many auto-injectors should be available to severely allergic patients at any one time? — Severity of reactions: Can it be determined which patients are at risk of life-threatening reactions and those that are likely to experience only mild ones? What percentage of people diagnosed with food allergy react to casual contact with an allergen (smell or touch)? What are the implications with regard to airline travel or being in another enclosed space such as a public house or club? — Psychological eVects: Are allergic children as anxious about coping with allergy as their parents? allergy: evidence 179
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— Development of allergy: Can sensitisation be prevented through pre-natal, weaning or early life interventions. How much does lifestyle increase the chance of becoming allergic? Why do people develop allergies later in life? Why does an apparently mild allergy become more serious during a person’s teens? — Emerging allergens: Can the risks posed by new allergens, such as lupin flour, be quantified so that appropriate advice may be given to those who may be at risk?
Conclusion 8. Even with a correct diagnosis, those living with severe allergy face a huge battle every day and their quality of life and that of their extended family is greatly aVected. The shortage of information from the NHS, means that for many little is known about a potentially life threatening condition. The Anaphylaxis Campaign has 7,904 members who benefit from a newsletter three times a year and regular bulletins and updates but the estimated figure for those with allergy severe enough to require specialist care is up to three million. This means there is a huge shortfall of people who are not aware of all the facts and could be living without a suitable self-management plan. Quality of life is also compromised by the feeling of being out of control. The allergic population is reliant on the food industry to label correctly and the medical profession to diagnose and treat eVectively. Both areas are flawed due to lack of services, education and knowledge. 9. We welcome the House of Lords Select Committee on Science and Technology’s investigation and are available to oVer further information on request.
REFERENCES [not printed]
Supplementary memorandum by The Anaphylaxis Campaign Adrenaline auto-injectors in schools Background: Children with severe allergies face some risk when they leave the relatively safe environment of the home and face the unpredictable environment of school. Their parents suVer high anxiety levels. The Anaphylaxis Campaign believes the risks can be managed and minimised. What school nurses and staV need is information and training. Training should include instruction in the use of adrenaline auto-injectors. Unfortunately schools are hampered by a lack of national guidelines for the prescription and use of auto- injectors. There is no consensus about which children should be prescribed them or how many should be available to each child. Evidence of need: During 2006, the Campaign helpline took 4,563 calls. School problems were among the common recurring themes. Knowledge about the use of auto-injectors among UK schools is patchy. In worst cases, schools and pre-schools have eVectively excluded children who carry auto-injectors. There is published evidence to support the Campaign’s experience: — A survey in the Severn NHS area found that 44 per cent of schools with an allergic pupil either did not have staV trained to administer medication or declined to respond to the survey. Less than half of the schools with nut-allergic children said they gave relevant information to all teachers. — In the Hull and East Yorkshire area, 82 per cent of schools surveyed had no policy on allergic reactions, 55 per cent had no training to deal with reactions and 67 per cent wanted training. — An audit of schools in Nottingham identified inconsistency in knowledge and awareness about treatment of allergies. Gaps in training for school nurses and school staV were identified. — A survey by the Campaign of 14 school nurses in the West Midlands showed that all would welcome training by the Campaign. The West Midlands is an area where allergy awareness in schools is already high, indicating that training is probably more urgent in other areas. Addressing the unmet need: The Campaign is meeting an unmet need by running a national training programme for school nurses. This has been successfully piloted in five areas of the UK. However, the national roll-out is subject to funding becoming available. Generic auto-injectors in schools: We believe a solution to the lack of consistency in schools on the carrying of adrenaline auto-injectors could be to have generic auto-injectors available in schools where there are severely allergic children. Under this model, each child who had been prescribed adrenaline would have their own injector available. The generic injector, held by the school, would be available for any child who may need a 180 allergy: evidence
31 January 2007 second dose. Subject to funding, a scheme along these lines will take place in Basingstoke from September 2007. The project has been devised with full input from the local allergy service, GPs, schools and school nurses.
Memorandum by Dr Richard Pumphrey
Fatal Anaphylaxis (Fatal Acute Allergic Reactions) The UK fatal anaphylaxis register has attempted to record every fatal acute allergic reaction in the UK since 1992 and is the most accurate source available in the world for statistics on fatal anaphylaxis. From 1992–98, around half the UK fatalities were to medical interventions such as drugs used in anaesthesia or injections for special X-ray investigations. The remainder comprised fatal reactions to stings and to foods together with rare causes such as anaphylactic reactions to latex, hair dye, parasitic worms (hydatid cysts) and so on. Fatal anaphylaxis to food in the seven years 1999–2006 has followed a very similar pattern to the previous seven years: the data for stings and drugs is incomplete and further study is needed; from the data in the register so far it seems probable that the pattern will also be similar to the previous seven years. A third of the population suVers from allergy but mostly their reactions are not dangerous. At least one person in a thousand has one or more serious reactions but fewer than one in a million will die from their allergy; of those who die, over half did not have any previous serious reaction, which makes it very hard to know who should take specific precautions, such as carrying an adrenaline pen for emergency self-treatment. Of the last 48 fatal reactions to foods, adrenaline pens had been provided to 19 (40 per cent) including 11/13 with previous severe reactions. Despite this, the rate of food allergy deaths is somewhat higher than it was in the previous seven years when fewer had pens. The reason the pens failed was in some cases obvious (pen time-expired, pen used too late in the reaction, pen not carried that day). Some of the pens may have failed because the patient was too fat for the pen to give the necessary intramuscular injection. Others used the pen correctly, were thin, had the correct dose and still died. One 16-year-old girl took the risk of eating a chocolate labelled “may contain nuts” because she had her pen with her. She used the pen immediately she saw nuts in the chocolate but nevertheless died from her reaction. Clearly pens cannot be relied upon to save someone with a food allergy reaction and patients must continue to take great care to avoid their trigger food even when they have a pen. It seems that the mechanism by which anaphylactic reactions are fatal depends on the patient’s state of health. Those with asthma will usually die from an acute attack of asthma brought on by the allergic reaction; for such people, optimal daily control of their asthma will protect them from a fatal allergic reaction. Those with heart disease are more likely to die from shock; medical treatment for raised blood pressure makes allergic reactions more severe. Rarely, inflammation in other sites such as around the brain will be aVected during an anaphylactic reaction, leading to diVerent mechanisms of fatality. In some cases a very severe allergic reaction can kill an otherwise fit and healthy person by redistribution of the fluids in the body leading to shock; in such cases an upright posture may make an otherwise survivable reaction fatal. These and other observations from the fatal anaphylaxis register have provided the evidence for logical treatment guidelines for anaphylaxis. The details of new cases on the register still provide new insights and it is essential this recording is continued in the future. 15 January 2007
Examination of Witnesses Witnesses: Ms Mandy East, National Co-ordinator, Anaphylaxis Campaign; Professor Gideon Lack, Head of the Paediatric Allergy Service, King’s College London, Guy’s & St Thomas’ NHS Foundation Trust; Dr Richard Pumphrey, Consultant Immunologist, St Mary’s Hospital, Manchester; and Mrs Hazel Gowland, Allergy Action UK, examined.
Q433 Chairman: Can I welcome you all here today Mrs Gowland: I am Hazel Gowland. The reason why and thank you for coming. The individual members I am here primarily is because I have a severe, of the Committee will not be declaring their interests potentially life-threatening allergy to nuts and as we go round because that has all been noted in a peanuts. I have a number of hats. You have called me separate document. I wonder if I could start oV by today as Allergy Action. Allergy Action is basically asking you to introduce yourselves and then we will me; I am self-employed. I have a sole trader business go into questions. but I also work for the Anaphylaxis Campaign. As allergy: evidence 181
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland
Ian mentioned I am the person who has been intolerance and food anaphylaxis. Dr Pumphrey, delivering all this training. I have a number of roles would you like to start? to play. I give free information to anybody who is Dr Pumphrey: People can obviously react adversely allergic who ever asks me for help. I have a formal to food in a number of diVerent ways. At one end you role as the food adviser for the Anaphylaxis have toxic reactions where nearly everybody would Campaign which is varied. It has involved liaising react to that food with an adverse response. Then with Sue and the FSA team on all the policy there are diVerent types of hypersensitivity reaction documents and these pieces of guidance and so on. I where most people can tolerate the food but for also work with Dr Pumphrey on analysis of where particular individuals that food will cause a problem. people get caught out with allergic reactions so I have Those are now divided into those who have an a research role from the practical, human point of allergic basis (that means anything that is view. I am delivering the training for the Food immunological) and those which are due to Standards Agency and for the project in Northern other mechanisms. So you have non-allergic Ireland and across the border for the environmental hypersensitivity or you have allergic hypersensitivity. health oYcers. Independently I also made a training Allergic hypersensitivity is now also divided into that DVD which I think I sent you. I do not know whether which is IgE-mediated and that which is not (IgE is you have seen it, but it is an accessible training pack the allergic kind of antibodies that we can measure in for caterers. I train caterers and other food handlers a laboratory, which you get measured if you have an including schools, nurseries, childcare, chefs, et allergy test for example). Those are the principal cetera who call me on a commercial basis. diVerent types of adverse response that you can have to a food. Q434 Chairman: Thank you. Dr Pumphrey? Dr Pumphrey: I am Richard Pumphrey. I have many Q436 Chairman: Could I just ask you, is so-called years’ experience in allergy clinics and in running a oral allergy syndrome a true allergy? Health Service laboratory that undertakes allergy Dr Pumphrey: Yes. Oral allergy syndrome is generally investigation of patients. My particular expertise caused by an IgE-mediated response. The allergic here is that I have made a special study of everyone antibodies are key to the oral allergy syndrome. The in the country who has died from an acute allergic reason it is only oral allergy is that the things you are reaction to food and that has produced a lot of new allergic to in the food are very labile, they are insights into what the problems are. destroyed by acid in the stomach and so the allergy does not spread beyond the mouth. It also needs to be Professor Lack: I am Gideon Lack. I am a consultant something that is absorbed through the membranes in paediatric allergy. I work at King’s College in the mouth to cause a local response there. London and St Thomas’ Hospital. I have been practising paediatric allergy for the past 15 years; my particular area of interest is systemic allergic disease Q437 Lord Taverne: Could you remind me about the or complex allergic disease in young children. I am non-IgE allergic response basis for that? mainly interested in the rise in food allergies and what Dr Pumphrey: An allergic but non-IgE response may be the causes behind them and how to prevent typically would be something like gluten sensitivity them, particularly the relationship between early diet where there is an immunological process underlying in the first year of life and subsequent development of this in that you have IgA antibodies against one of allergies. My other particular area of interest is severe the components of the food but also you have auto- or diYcult asthma in childhood and the role of immune response involvement as well and the allergies in contributing towards this. lymphocytes are involved in the response, so you get Ms East: My name is Mandy East. I am the national a local destructive response in the lining of the gut, co-ordinator for the Anaphylaxis Campaign which is for example, as a result of eating food that contains a national support organisation for those living gluten. That has an immunological basis to it but it is with the most severe of allergies that could lead not IgE-mediated. to anaphylaxis. I also represent the Anaphylaxis Professor Lack: Dr Pumphrey made some very Campaign to the National Allergy Strategy Group important distinctions and in clinical practice we see V which is the coming together of many patient support these di erent sorts of reactions being manifested to groups and medical professionals set up to improve the same foods. Part of the confusion can be in allergy services. disentangling these diagnoses, sometimes they may even co-exist. To give an example, I may see a six- month old baby who comes in with eczema who has Q435 Chairman: Thank you. I think it would be tasted milk formula for the first time. The face helpful if I could ask you to start oV by explaining to immediately swells up, there is vomiting, there are us the diVerence between food allergy, food breathing diYculties; that is an immunological 182 allergy: evidence
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland reaction; therefore it is an allergic reaction. It is quick attention was drawn to the BMJ article of 2 on-set; it is IgE mediated and you can test for this September where experts Professor Colver and easily. In contrast a diVerent child could come in at Professor Hourihane give diVerent estimates of the six months of age with severe eczema, diarrhoea, prevalence. How could studies be improved to more poor weight gain and has delayed on-set reaction to eVectively monitor the prevalence of food allergy, milk. Very often this child will have inflammation in intolerance and anaphylaxis? the gut; there are T lymphocytes in the gut that Dr Pumphrey: The key problem here is the are responsible for this. While this is also an distribution of severity. You have a lot of people who immunological response to a food and therefore have a very mild allergy and a few people who have represents an allergic reaction, it is a delayed non-IgE very severe allergies. It is a continuous distribution so mediated type of reaction. We are discovering a lot you have to make a choice as to where to put the cut- more about these delayed onset allergic diseases in oV point and a small change in your criteria could children and in adults. The third type of clinical produce a 30-fold change in the numbers of people presentation to cow’s milk would be a child who has you are counting. I do not think that technically you been drinking milk, who has had gastroenteritis, are ever going to come up with an accurate, precise often due to a viral infection, and then the gut stops figure. You can say that three per cent of the producing the enzyme lactase. This child has a population have food allergies providing you define metabolic deficiency—has a deficiency in the enzyme what you mean by it. Or you could say that one per lactase—and therefore cannot break down lactose cent of the population have food anaphylaxis and (which is the sugar present in milk) and consequently you might get agreement with people. You can quite has diarrhoea and other symptoms. This is not accurately say that only five to 15 people each year immunologically-mediated, and therefore is not an die from food allergies; you do have a cut-oV there. allergic reaction. It is often short-lived, but in some people who are genetically pre-disposed it may continue into adulthood. The same child may Q440 Chairman: Going back to the previous manifest all three types of allergies to cow’s milk at statement from Professor Lack, if someone has diVerent times in childhood. a mild, generalised reaction to food, is that anaphylaxis? If it is not, might that person go on to develop anaphylaxis on another occasion? Q438 Lord Colwyn: This is a question I should know Dr Pumphrey: I can answer that from looking at the the answer to, but when does a severe food allergy fatal reactions. Over half the people who die from a become anaphylaxis? I was under the impression food allergy never had a severe reaction before. The that anaphylaxis was when respiration becomes only reaction they had before was a mild reaction so impossible and the patient could die without medical clearly people can go on from having a mild reaction intervention. to the next reaction being a fatal one. Professor Lack: The term anaphylaxis is used to a Professor Lack: Just to add to that, there are certain V V certain extent di erently by di erent people and in risk factors for anaphylaxis. You can identify V some ways is viewed di erently by our North someone at high risk for anaphylaxis but you can American colleagues. Everyone is in agreement that a never confidently say that someone is at low risk. I life-threatening food allergy represents anaphylaxis; think that is an important distinction. I can see a child so one that causes compromise of the respiratory who presents with a mild egg allergy—this happens in system or compromise of the cardiovascular system clinic frequently—is given Piriton and told not to (drop in blood pressure); is considered life worry, the problem is going to go away. You do not threatening and therefore anaphylaxis. Some people see the child for a year and in the interim the child also call a systemic allergic reaction—one which develops asthma and some of these children may V manifests all over the body or on di erent parts of the develop diYcult asthma particularly as egg allergy body—anaphylaxis. In children who have a food and food allergies put you at risk for other allergic allergic reaction of the rapid onset IgE type (the face diseases. Once the child has asthma, particularly if swelling, for example), some 30 to 40 per cent of the asthma is poorly controlled and they encounter children at some point in their lives will have the food, then they have a much more severe reaction. respiratory compromise as a result of these reactions So seeing a child early on or even an adult early on and will need to seek medical assistance or need to use with mild symptoms does not reassure you, and does Y an asthma pump because of di culty breathing. not give you or the patient the confidence that the reactions will be mild thereafter. Q439 Lord Rea: From what has just been said it is Mrs Gowland: Some of the work that I do for the not surprising that the Institute of Food Research Anaphylaxis Campaign involves making contact has said that estimates of the number of people with families where somebody has died. Therefore I suVering from food allergy are imprecise. Our am able to work with Dr Pumphrey with the family’s allergy: evidence 183
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland consent, and this involves two things which would that my work with the Anaphylaxis Campaign has otherwise be unavailable. I can find out what led to talks, presentations and increasingly structured happened on the day in great detail with my own formats for diVerent audiences. The key audiences experience of having suVered allergic reactions and I now are various London boroughs who bring me in can also find out a lot more about their background to train food handlers generally and nursery staV, and the whole atopic history of the person on a very people managing small children in particular, not just informal level (I am not medically qualified but I the people feeding them but the people looking after understand their life). Therefore I can listen to them day by day because obviously those little mothers of young adults—it is often a 20 year old children, as Dr Lack has said, have a dynamic allergic person, maybe a 30 year old person—who say that status and require some supervision in their the doctor said it was a mild nut allergy when they environment. Then there are the large, reputable were two and they muddled along as I did through catering organisations, the kind of companies that childhood, a bit wheezy at parties, a bit sick but never will have in-house catering—also banks, insurance having fatal or potentially fatal symptoms until some companies, those sorts of people. I have worked for other time of life. We seem to pick them up in the John Lewis Partnership. Sometimes schools, adolescence and anecdotally that is the high-risk age sometimes regional branches of the professional for life generally. Lifestyle and life skills-wise you bodies—the Trading Standards Institute, the can understand why, say, first year students are Chartered Institute of Environmental Health—will particularly vulnerable. They are new adults, legally call me to give a talk for them. Now this is adult, away from home, choosing their own foods increasingly structured because of the work that I with new friends. Those are circumstantial issues am doing delivering these workshops. It started out apparently to do with allergy risk but too many of as a half hour presentation on somebody else’s them have had minimal symptoms in early programme and we have now got a five-hour all-day childhood. In a class of three-year-olds you would package. I was doing one of these FSA workshops not be able to distinguish between two children with yesterday in Lincoln with 20 trading standards and a nut allergy, which of those children might be the environmental health oYcers, funded by the FSA, one that might die from it later. which has been one of the goals of the Anaphylaxis Campaign for a long time. When I started calling for Q441 Chairman: Dr Pumphrey, from your database that six years ago I did not realise it would be down what is the age distribution of the deaths? to me to deliver it. I thought that something would Dr Pumphrey: It varies from one food to another happen, there would be a magic training fairy that curiously. Children dying from milk allergy the age would come and deliver this training, but it is me, so range is from five months to about 16; for peanuts it I am doing it. Those are my various ways of working. is from 13 to 26; for tree nuts it is from 18 to 36 (with a few older people as well). Then you have fish, Q443 Baroness Platt of Writtle: You cannot do all crustaceans and so on where we do not have large this on your own. You have talked about London enough numbers to talk about a proper distribution; boroughs, you have talked about schools, you have we cannot do statistics because there are so few cases. talked about businesses, but presumably there is a great need for people like you to be doing it on a Q442 Baroness Platt of Writtle: My question is to wider scale. Hazel Gowland. Allergy Action oVers advice and Mrs Gowland: That is my aim. It is fantastic work, it training on food allergen risk assessment and is very rewarding and we can make changes; we can management. What type of businesses request change the way people work. material or training from you and how does your work feed into the work of the Anaphylaxis Q444 Baroness Platt of Writtle: Do you have other Campaign? people working for you in that field? Mrs Gowland: When I joined the Anaphylaxis Mrs Gowland: The training yesterday was delivered Campaign as a member I thought I would be a very by the first person I have trained to deliver a ordinary member and there would be thousands of workshop. I go as an extra but it is a dovetailing people like me. I quickly understood that there were process and gradually she is taking more of the a lot of people in my generation who, at the time, had script oV me. Her background is that she was an young children and they were frightened for their environmental health oYcer so she has all the allergic young children whereas I was an allergic credentials of the local authority enforcement oYcer adult who was confident—I was a school teacher at and she now works in the private sector so she is the time—and so going into a room full of people and visiting and auditing every size and shape of business telling them about life is where this work started, and from huge factories down to little takeaways on a giving them confidence as well. That has developed so daily basis. I have had to teach her allergy and she has 184 allergy: evidence
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland taught me about her food safety world by return. I nuts—you have to remember that the allergen is think if anybody could do cloning that would be the protein within the nuts and it is extremely useful. transferable so if somebody is eating nuts it will be passed to somebody else through hand contact, Q445 Lord Taverne: There are two of you now but through hand to face contact and also through by the sound of it you need hundreds. discarding of the wrappers. Obviously, as we were Mrs Gowland: We do, yes. We do what we can. The saying before, the thresholds of what people will react Anaphylaxis Campaign has a special website which is to are unknown but certainly a local reaction is called cateringforallergy.org which we wrote—I put extremely likely if someone were to touch you after a lot of content into it—which is another place where they had been eating nuts. So although we are not there is credible information. I will train anybody to saying that all these reactions could prove fatal, we V deliver if they want to go and train. The NVQ are saying that it will directly a ect the quality of life question you asked earlier, it was 1995 when I went of the children attending the school. Anecdotally, to the training bodies for the syllabus for the training since this has come out and it has been well known of food handlers. I have been trying to get it on their that this is going to happen, we have had very worried radar but, as Dr Leitch suggested, getting new mothers and indeed worried young people speak to subjects on a fairly packed curriculum is not always us to the point where a number of children are scared easy. The other thing that was mentioned earlier to go to school. Also this leads into the worry of which I will say is that on my Allergy Action website possible bullying. This does happen, particularly in V there are translations for people to go on holiday and secondary schools, where if a child is di erent that V they can help themselves. I have translations in di erence will be picked up. Children have had nuts certain languages—as many as I have been able to put into their blazer pockets and into their lunch get—so people can talk to chefs when they go on boxes to try to contaminate their food. It is very holiday, they take a little card with them. There is a much an issue that we are working on and we are lot more work to be done. trying to educate head teachers and teachers within the schools, but also educate the peers and the young people themselves. As we have already heard, from Q446 Lord Colwyn: The Department for Education the ages of 11 or 12 upwards, up to when you would and Skills have a recommended list of healthy foods leave school and take on life independently, you are which of course includes nuts and seeds and no doubt at an extremely vulnerable stage in your life. The kiwi fruit. Do you feel that children with food Y answer to the question is that we are not particularly anaphylaxis or a tendency to that are su ciently happy about it but we are working very carefully to protected in their school? make sure that if it happens it happens in the safest Ms East: The Anaphylaxis Campaign have done a lot way possible. of work on this and we do not advocate nut bans in school; we have never been of the opinion that you should ban all nuts and all major allergens in schools. Q447 Lord Colwyn: Can anything more be done to We believe more that management and for the child prevent this casual contact with these allergens? So to learn to avoid is much better in equipping the child far as I am aware, even handling a banister which has for later life. However, with the Department for nuts on it from hands can trigger an anaphylactic Education and Skills suggesting that nuts and seeds shock? Or is that not right? Is that very rare? are deliberately brought into schools we have had to Dr Pumphrey: We have looked at the source of take a stand. At present a vast majority of primary allergen and severity of reaction, and in general, schools and certainly pre-schools do not have nuts in environmental contamination leads to a relatively school deliberately and a lot of them actually ask mild to moderate reaction, not the most severe ones; parents not to send nut products and in some cases it is very unusual to get such a severe reaction. milk and egg products in with children’s snacks or Contamination can happen but nearly all the packed lunches. With the primary schools this will fatal reactions have happened from intentional probably be managed within schools because there is ingredients. a great knowledge amongst head teachers that they Ms East: Can I just add to that that we do agree with need to be keeping their allergic children safe. what Dr Pumphrey has just said. We are of the However, our concerns are secondary schools where opinion that the allergic population need to be more the children are much more independent, have aware of the type of reactions they are having. control of their own money and a lot of these snack However, for someone who is not medically trained products will be provided through vending machines and a young person who does not really know very so there will not even be any human contact when much about their allergy it is still extremely scary to people are buying the products. When you are have a local reaction because they do not know and looking particularly at nuts—peanuts and tree do not have the knowledge—because they are allergy: evidence 185
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland not seeing allergy specialists to give them that qualified children’s nurses, and this means that they knowledge—how that reaction will turn out. There is will all have had some training and experience in then a level of panic. That can lead to a diVerent type the management of anaphylaxis”. How does the of reaction like a panic attack or some type of worry Anaphylaxis Campaign respond to this assurance? because they do not know what is going to happen Ms East: Obviously the statement is not untrue, even though we know that medically it is very rare for however a lot of school nurses had their nurse you to have anaphylaxis through local contact. training many years ago—some up to 30 years ago— and a lot of them do not have the training in Q448 Lord Colwyn: I am feeling rather humble in anaphylaxis that is needed today. A lot has changed fact because my youngest daughter works for the in the management of anaphylaxis and the treatment advertising agency that does Mars and Snickers. I am of allergies in general, certainly over the last 30 years. just wondering whether the manufacturers of these Even more recently the way that the adrenaline auto- sweets that contain nuts are doing enough to prevent injector is given has changed and a lot of nurses will the problem? not be aware of that change because once they have Mrs Gowland: You heard from Sue Hattersley from had their training in order to qualify them there is no the Food Standards Agency this morning and if we obligation for them to be retrained or have any are honest, in the UK these things are better dealt refresher. Obviously we agree that school nurses are with than they are across the Channel and probably trained nurses, however a lot of research is being in America as well. The nature of the relationships done into schools and the school system and whether between the consumers and the manufacturers and the nurses and medical professionals in charge are the retailers and those who influence controls and able to cope. In the Select Committee for Health labelling is excellent; we really do have very close report in 2004 a survey conducted in the Hull and relationships. There are some insurmountable Yorkshire area of the country showed that 200 problems. One of them is that you do not wash in a schools were surveyed and 82 per cent of those chocolate factory because water in a chocolate schools had no policy for dealing with allergy and factory adds a microbiological risk so if you want to anaphylaxis yet they had children within the schools clean a chocolate line what you do is just push more who were actually living with those conditions, and fat down the line and it is supposed to pick up the they were schools with school nurses in so those contaminants or whatever along the way, or you school nurses were not confident enough to give the push chocolate through the line. Anecdotally I have adrenaline auto-injector if needed or manage local had a life threatening episode when I was at a high reactions. The Anaphylaxis Campaign are now in the risk age from a chocolate that was not meant to second stage of a UK-wide project in order to train contain nut but had picked up some contamination school nurses and the background for doing that probably because of rework. That is another thing showed that there was a definite, genuine need to get that happens in factories, you recycle something that school nurses trained to a level where they can was not used and you put it back in. You can take the actually administer medication as needed or just chocolate oV the wonky ones and put it back in the manage the reactions in children. To date 99 nurses system and make new chocolates. There are some have been trained and of those trained 21 told us that things which are very diYcult to manage. There are they had never had any form of training for allergy some companies that have gone to great lengths and training beforehand. I think that shows how we react even made it their main purpose to exclude particular to the statement that we are not disputing that school allergens from their production, but there are some nurses are trained nurses, however they are not Y very practical issues and if you think that the aim of su ciently trained in dealing with allergy and a manufacturer is to make things as cheap and simple anaphylaxis. as possible, which essentially means having the most flexibility between what you run down a line and Q450 Lord Taverne: Could you give us some keeping the line going night and day so that you can assessment of what you think of the treatment within get the best use out of your resources, whereas the the National Health Service of patients with food optimum for the allergic consumer is to have allergy and anaphylaxis and the quality of the advice separation, segregation, protection, limits (ie changes they are given about managing their condition? of uniform, controls of air, lots of extra hand washing Dr Pumphrey: That is a diYcult question. It is diYcult and so on). You can see that there is a crunch there because I think the standard of care diVers across the and it is always going to be a compromise. country. There are diVerent areas and diVerent practices. Partly it is due to diVerent opinions about Q449 Viscount Simon: In oral evidence the what the correct management is. One could take a Department for Education and Skills said that “all simple example, adrenaline pens. There is a range of school nurses are trained nurses and many are opinion across the country as to who it is appropriate 186 allergy: evidence
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland to give an adrenaline pen to. In some areas they will Q451 Lord Taverne: In this depressing picture are be given to anyone with mild allergy. If you are there any particular areas which are even worse than managing someone with asthma and peanut allergy others? The treatment of immunotherapy, diagnosis? they will automatically be given an adrenaline pen. In Is there any special weakness that one should be other areas there is a great resistance to this because aware of? it is thought that the evidence of these pens being Mrs Gowland: The most frustrating thing is that helpful is not that clear. There are some people for allergy is cheap. I live with allergy; I am not using whom adrenaline pens are less likely to be eVective, adrenaline injector pens because I am very good at for example people who are overweight may not get avoidance. If a person is more sure of what they are benefit from them. There are a lot of ifs and buts. I allergic to and how they can avoid it, then their life think the quality of care across the country is patchy. will improve. It is a whole life thing. If they are in a Professor Lack: I would have to agree that the quality woolly haze and hanging on a waiting list or is patchy but overall if you look at numbers of desperately trying to pay for some alternative allergy specialists in the country in adult allergy and option for diagnosis, then they will be in a muddle. paediatric allergy, we are not only the poor man of The best way to live with allergy is to be sure of as Europe but to a certain extent the poor man of the many things as possible: sure that you need your world because we do not have specialists and if you medication, sure of the potential risks that you might do not have specialists it means you do not have react in a world where everything is basically people in secondary care or in primary care who unpredictable. I believe that within a practice or know much about allergies. There is a general lack of within an area, a GP might learn up allergy and knowledge about allergies right across the board. become the one that is better at it than the others, that Sweden has 96 paediatric allergists paid for by the might be a way for people to be pointed in their health care system; the UK has a handful, most of direction. The lifestyle stuV, the additional coping whom are on academic funding. The numbers reflect management work could be done with the practice similar under-staYng in adult allergy. I am sure you nurse. If somebody is going to train you how to use have heard evidence on the prevalence of allergic your injector, to sit with you perhaps even with a disease and it is no remarkable coincidence that the dietician and work through what you need to avoid waiting lists for allergy clinics have sky rocketed and and where you might get caught out, then that might are very diYcult to control, particularly within be a way to cover daily management apart from Government waiting-list targets at the moment. The going to the proper clinic to see an expert. What patients who manage to come to our clinic do so via happens at the minute of course is that first of all a very convoluted process. They often come after nobody is looking at whole people, they look at it by years of having allergic disease without proper organ. How many parents of dead young people say, treatment. We see on a daily basis children coming “I didn’t know their asthma was anything to do with into our clinic who have asthma, bad eczema, hay it” whereas we know that if you keep up your preventer medication you will be armed better to fever, multiple food allergies. Their asthma is not cope with reactions than others who don’t. That is properly controlled; they have not been diagnosed simple and it is frustrating that you cannot do that. properly; they have not been told specifically what These things are not expensive. Even carrying foods to avoid; they keep having reactions and this is injectors is not that expensive compared with not acceptable. operations and interventions and so on; this is a Ms East: Can I just add as well that from a patient relatively cheap thing to get right if the right people point of view the problem is not just there are not are in the right place and are accessible. enough specialists, there is a lack of knowledge in Dr Pumphrey: The great diYculty about being a primary care so many people will present to primary general practitioner is that you are just that and you care with allergic disease and quite often that allergic have to be able to cope with everything that comes to disease should be managed within primary care, there you. Over the last few years we have made great use is no need for a specialist appointment. However, of specialist nurses in the hospital practice and we there is a fear with the parents or the allergic person were looking at the possibility of having specialist that they must have some specialist care. There is not nurses who would go and help the general the specialist to refer to, the GP does not know how practitioners with their allergy patients. From the to manage it and so they are often referred to the point of view of screening out those who can be dealt wrong specialist. So somebody who presents with with at a local level and those who do actually need eczema might be referred to a dermatologist but they specialist referral I think that that kind of system do not actually get to the root of the problem. There could be an economical way of approaching it. is not the holistic approach to allergy. The people we hear of are coming to us for advice because they are Q452 Earl of Selborne: Is there a risk that genetically not getting it from the National Health Service. modified food may introduce new allergies? allergy: evidence 187
31 January 2007 Ms Mandy East, Professor Gideon Lack, Dr Richard Pumphrey and Mrs Hazel Gowland
Professor Lack: I do not believe the risk of genetically are there adequate facilities for diagnosing and modified foods introducing new allergens is any managing drug allergies? greater than the risk of introducing novel foods, Dr Pumphrey: That is a very long and diYcult naturally produced foods. There is always a risk question. I attended a three-day conference in when you introduce a new food into a society or into Liverpool on that topic which barely scratched the a culture that allergies to that food will develop. That surface. The long and short of it is that there are has been the case with sesame seed and kiwi for many diVerent types of allergic process and drugs can example. We did not eat kiwi fruit 50 years ago and trigger any of them. Some of them are IgE-mediated we did not have kiwi allergy in this country. like the ones we have been talking about, some of Intrinsically there is no increased risk by the process them are IgG-mediated, some of them are cellular of genetic modification of producing more allergenic mechanisms and some of them work through even type foods. more convoluted processes. We are very bad at recognising which drug is causing which and Q453 Earl of Selborne: Conversely is there any something as simple as penicillin will cause many possibility of reducing allergens by use of GM food? diVerent types of allergic response. Some of them are Professor Lack: No, you should not increase the risk dangerous, some of them are not and it is very of producing allergens by GM foods. In theory a diYcult to predict with any individual patient who mistake could occur where an allergen in an existing has had, for example, a rash from penicillin, whether food—a protein in an existing food—that causes their next dose will be tolerated without any allergies is transferred into another food but that will problems or will cause a major reaction. It is a Y not happen because we know what these allergens di cult area and in the Health Service we have very are. Whenever a gene is transferred identification of few clinics that can cope with this and also there is a that gene is made. If it is a known allergen it does not range of opinion within the clinics about how useful take place. the tests are that we use to investigate these allergies. Q456 Chairman: Is it being done better in other parts Q454 Lord Taverne: Is there any prospect in the of the world? foreseeable future that work done, for example by Dr Pumphrey: I do not think it can be done much Buchanan and his colleagues in the United States, better, but I am sure the French would say that they could produce some sort of elimination of the do it better because they have far more clinics and allergenic properties of certain kinds of food? they have more people interested in the subject and Professor Lack: One of the problems is that most are prepared to look into patients very readily. foods that cause allergies, it is multiple proteins Professor Lack: I agree that the mechanisms are within the food. If you are going to genetically complex; a lot more work needs to be done on that. modify each protein you will end up with an One of the problems is that the perception of drug V essentially di erent plant and that plant will lose its allergy, particularly penicillin allergy, is much higher properties that give it its taste and appearance that than the reality. One of the jobs of the allergist is to make it a favourite food. However, what I would say undiagnose drug allergies and in childhood up to is that genetic modification at the level of individual 10 per cent of children—or the families of these proteins in a food may give rise to a plant that is not children—may think they have a particular drug particularly tasty but to a product that can be used allergy to a common antibiotic which means they V for medicinal purposes to try to switch o allergies never get that antibiotic and it makes clinical practice because that product becomes tolerated in the very diYcult. The tests are not perfect but a good allergic patient. It could be given in an injectable clinic should be able to sort out which child has form or in an oral form or together with some other allergies and which does not and tell them which medication to try to desensitise the patient in a safe antibiotics are safe. We do need more specialist way. There are a few groups working on that clinics. principle, the idea of making a hypoallergenic peanut Chairman: In the light of your experience, Dr or some other food that you could then treat the Pumphrey, I wonder if you might like to write in after patient with to desensitise them. this session a short piece perhaps summarising what you learned in three days at Liverpool and also from Q455 Chairman: How is drug allergy distinguished your own personal life’s work experience because I from other forms of adverse reactions to medicines? think it will be very valuable to us and we have not Is there adequate data on the prevalence of drug been able to do justice to that in this session. May I allergy in the UK and who records it? How are thank you all for coming and for having informed patients with drug allergy managed in the NHS and our deliberations. 188 allergy: evidence
31 January 2007
Supplementary memorandum by Dr Richard Pumphrey, Consultant Immunologist, St Mary’s Hospital, Manchester At the meeting on 31 January, Baroness Finlay of LlandaV asked me to prepare a brief written statement about the investigation and treatment of drug allergy. Almost every drug has caused adverse eVects in a proportion of those being treated. The range of these eVects is wide and the underlying mechanisms varied and often poorly understood. When the drug reaction is due to hypersensitivity, this may be non-allergic or allergic, and if allergic, may be IgE-mediated29 or non-IgE- mediated.
IgE-mediated Drug Allergy This type of reaction characteristically causes rapid development of symptoms after exposure to the drug, commonly including rashes or swellings but in more severe cases involving shock or diYculty breathing. Tests for this type of allergy are based on the binding of the drug to IgE in a specimen of the patient’s serum, or by challenge with a small quantity of the drug by skin prick test. More reliable but potentially dangerous is a drug challenge (drug provocation) test, when the patient is given a dose of the suspected drug under conditions where it is hoped the adverse eVect will be limited and the patient can be rescued from any reaction that occurs. The most severe form of IgE-mediated allergy is termed anaphylaxis. In the UK around 10 deaths are attributed to drug anaphylaxis each year.
Non-IgE-mediated Drug Allergy Many diVerent processes are lumped together under this heading, previously grouped as type II, type III and type IV hypersensitivity. Some can be tested in the laboratory, some by skin tests, some by microscopic examination of biopsies. Some mechanisms thought to occur in humans by extrapolation from the results of animal experimentation cannot yet be routinely investigated in the clinic or laboratory. The most severe forms of non-IgE-mediated drug allergy include a group of related conditions known as Stevens Johnson Syndrome and Toxic Epidermal Necrolysis. A few patients die from these conditions each year. The least severe reactions include drug rashes: these are very common and mostly cause problems because they are thought to signify the potential for a more serious reaction if the patient is given that drug again, leading to future treatment with more expensive and sometimes less eVective or less safe alternative drugs. Unfortunately we do not have reliable tests that will allow us to assess the risk of a recurrence of the reaction, though in most cases it is probably rather low.
Non-allergic Drug Hypersensitivity Many diVerent processes fall into this category. For example, angiotensin converting enzyme (ACE) inhibitors are widely used for treatment of blood pressure. These are good eVective drugs but cause side eVects in a small subset of those taking them, for example swellings that may be fatal if they occur in the throat and block the airway. The mechanism for this is known in considerable detail and there is potential for simple tests to predict who might be aVected—however, in practice the drug is given to anyone who might benefit and those who react are then changed to an alternative treatment; this approach results in one or two deaths each year. Many other examples could be given, often dependent on single gene diVerences aVecting the metabolism of the drug or the structure of receptors that can bind to it.
Treating Drug Allergy Although much is understood of the principles of diVerent drug reactions, it is usually diYcult in any individual case to be sure that which mechanism is truly the cause of the reaction. The usual management is to avoid the suspected drugs in future and use alternatives that are thought to pose less of a risk. Often one has to balance the risk of avoiding the suspect drug against the risk of using it despite the suspicions that it may have caused a reaction. 29 IgE is the abbreviation for immunoglobulin E, the class of antibodies involved in triggering immediate-type allergic responses. allergy: evidence 189
31 January 2007
A particular set of problems is caused by reactions during anaesthesia. Most of the fatal drug reactions are of this type and have been thought to be due to muscle relaxants, opiates or antibiotics. One diYculty is due to modern anaesthetic techniques where multiple drugs are given in quick succession at induction of anaesthesia; this can make it diYcult to identify which drug was to blame. Further research is needed to improve the sensitivity and specificity of the tests used to investigate such reactions.
Specialist Clinics for Drug Reactions This brief synopsis should make clear the diYculties faced by those who have reacted to a drug. They are unlikely to get ideal advice from any but the best informed of specialist clinics. I recently undertook a survey of the majority of UK clinics oVering this type of testing. The variety of approaches and heterogeneity of findings suggests the need for further research into the most eVective approaches and guidance for such clinics to raise the standard of all to that of the best. 190 allergy: evidence
WEDNESDAY 7 FEBRUARY 2007
Present Colwyn, L Platt of Writtle, B Finlay of Llandaff, B Rea, L (Chairman) Selborne, E May of Oxford, L Simon, V Perry of Southwark, B Taverne, L
Memorandum by the Chartered Institute of Environmental Health (CIEH) The CIEH30 is a professional and educational awarding body with some 10,500 members working both in the public and private sector, many of whom are at the forefront of tackling poor health and housing conditions. According to a recent report31 from the Department of Communities and Local Government (DCLG) there are 3.2 million vulnerable households living in the private sector in 2005 of which 1.1 million live in non decent homes.32 The existing Government target will still leave over 800,000 vulnerable households in non decent homes in the private sector by 2020. In contrast the target is for all social housing to be made decent by 2010. Recent research carried out on a SheYeld Decent Homes health impact assessment, “Decent Homes: Better Health”,33 has produced evidence that demonstrates the health benefits of making homes drier and warmer. A conclusion made from this is that children will be the main beneficiaries with a reduction of the likely incidences of Asthma. Since April 2006, the HHSRS provides a tool for local authorities to deal with conditions that include respiratory and allergic attacks. The system has used available evidence to support the approach of hazard assessment and, in this instance, it is particularly relevant for the hazards of excess cold, damp and mould and domestic hygiene, pests and refuse. Local authorities have enforcement powers to improve conditions in the private sector but whilst they use those powers when and where necessary in the private rented sector they are reluctant, for obvious reasons, to use them on owner-occupiers. Enforcement action alone cannot be expected to improve poor housing conditions and more incentive is required to encourage all home owners to repair and maintain their homes, particularly owner-occupiers. The Home Information Pack, being introduced by DCLG, provides an opportunity to improve matters but the inclusion of a house condition report is voluntary so there is still insuYcient emphasis on the condition of homes compared with their value. The CIEH has formed a Commission on Housing Renewal and Public Health34. The Commission’s interim report has found that the rate of replacement of very poorest areas of housing has fallen to very low levels. It is inevitable that in these poorest areas of housing there is an increased risk of exposure to allergic conditions yet the assessment of these areas lacks any specific reference to health. The Commission recommends, amongst other things, that the DCLG guidance on Neighbourhood Renewal Assessment35 is revised to include a health impact assessment of the diVerent options for action. Internationally, particularly in Europe, a great deal of work has been done on air quality and its harmful eVects. In particular, the World Health Organisation (WHO) Europe has developed a number of projects in the last few years. One such project has been to develop indoor air quality guidelines. Another is the children’s environment and health action plan for Europe (CEHAPE) which has produced a table of child specific actions for member states including indoor and outdoor exposure to allergens. They also have been developing environmental health information systems (ENHIS) which includes information on the health impacts of poor indoor air quality and suggestions for policies in relation to this. 30 Fuller information on CIEH can be found on the website http://cieh.org/ 31 English House Condition Survey—2005 Headline Report, January 2007. 32 Decent home: is one that meets the following four criteria: (a) It meets the current statutory minimum standard for housing (fitness standard for the reporting period of this survey)H. (b) It is in a reasonable state of repair (related to the age and condition of a range of building components including walls, roofs, windows, doors, chimneys, electrics and heating systems). (c) It has reasonably modern facilities and services (related to the age, size and layout/location of the kitchen, bathroom and WC and any common areas for blocks of flats, and to noise insulation). (d) It provides a reasonable degree of thermal comfort (related to insulation and heating eYciency). H From April 2006 the fitness standard was replaced by the Housing Health and Safety Rating System (HHSRS).] The detailed definition for each of these criteria is included in A Decent Home: Definition and guidance for implementation, Communities and Local Government, June 2006. 33 Decent Homes: Better Health, SheYeld Hallam University, July 2006. 34 Fuller information on CIEH can be found on the website http://cieh.org/library/Knowledge/Housing/HOUSINGpercent20COMMISSION.pdf 35 ODPM 2004, Neighbourhood Renewal Assessment: Guidance Manual, London. allergy: evidence 191
7 February 2007
In America, a study36 has confirmed that the presence of rat and mouse allergens in the home as being associated with asthma attacks. This is also a concern bearing in mind the reported increase in the rodent population in the UK in recent years. A similar study37 has demonstrated the potential harmful eVects associated with cockroach allergens.
Examination of Witnesses Witnesses: Mr John Bryson, Chair, Commission on Housing Renewal and Public Health, Chartered Institute of Environmental Health, Professor Adnan Custovic, Professor of Allergy, University of Manchester, Dr Paul Harrison, Director, Institute for Environment and Health, Cranfield University and Mr Grant Ager, Director, Fairfield Housing Cooperative, examined.
Q457 Chairman: Good morning and thank you for UK suggests that children with hayfever are twice as coming. The session is being web cast. I am Lady likely to drop grades in their GCSEs as compared to Finlay and I chair this Select Committee inquiry. children without hayfever. If, on top of that, they There is a paper declaring the interests of the take sedating antihistamines for the treatment of the members of the Committee so we will not be disease this risk goes up three fold, so you may be two reiterating those as we go round today. I would like to three fold more likely to drop a grade between the to start by inviting you to introduce yourselves and mock exams in December to the real exams in June then we will start asking questions. Would you like to when the hayfever season kicks in. That is much, start, Mr Bryson? much more than a simple case of sneezing and a Mr Bryson: Good morning. My name is John Bryson runny nose. Clearly not only can it aVect the way you and I am here representing the Chartered Institute of feel, but it can aVect the long term prospects in life of Environmental Health. I am the Chairman of their quite a substantial proportion of our children. Let us Policy Development Board and recently chaired a not forget that all the major exams take place exactly commission on housing renewal. during the time of the year when pollen levels are Dr Harrison: Good morning. I am Paul Harrison, highest. This is not a disease to sneeze at. Director of the Institute of Environment and Health at Cranfield University. I am a toxicologist interested Q459 Chairman: Can I ask if our other witnesses in the interactions between environmental factors want to add anything to that? and human health. Dr Harrison: I would just add that it can be Mr Ager: Good morning. I am Grant Ager, Director debilitating in the sense that a child with asthma or of Fairfield Housing Cooperative in Perth who allergic rhinitis is likely to opt out of sporting commissioned one of the first allergy homes in the activities so not only might it aVect their learning UK. abilities but also their well-being in the sense of Professor Custovic: Good morning, I am Professor being fit. Adnan Custovic. I am Professor of Allergy at the University of Manchester. Q460 Lord May of Oxford: We have heard that the hygiene hypothesis suggests that better living Q458 Chairman: I would like to start by asking all of standards these days and increased hygiene is the you how allergic diseases such as hayfever, perennial cause of the rise of allergenic disease. I wondered if allergic rhinitis, allergic asthma and atopic eczema you could tell us a bit more about the extent to which impact on the quality of life of suVerers. this idea is borne out by evidence and understanding Professor Custovic: Obviously talking about life and is not just correlation without causation. threatening diseases like anaphylaxis is quite easy but Professor Custovic: Hygiene hypothesis within the what I would like to emphasise is the enormous context of allergic disease was proposed in 1989. It is impact that a disease as simple as hayfever—allergic still a hypothesis so I think that says it all. It is still a rhinitis—can have on quality of life of suVerers. Let working hypothesis. It is in a great umbrella under us not forget that this is a disease that aVects almost which we are looking to understand the cause for the a quarter of our children and young adults. A lot of incredible increase in allergic diseases that we have people in primary care in particular would say that it witnessed over the last 30 to 40 years. Let us not is just a little bit of sneezing and runny nose. I put to forget the increase has been three to four fold you that it is much more than a bit of sneezing and thus allergy epidemics are environmental. Hygiene runny nose. Some fabulous recent evidence from the hypothesis is one of the working hypotheses, 36 Cohn R D et al (2004). National prevalence and exposure risk for mouse allergen in US households. Journal of Allergy and Clinical Immunology, 113:1167-1171. 37 Cohn R D, et al (2006) National prevalence and exposure risk for cockroach allergen in US households, Environmental Health Perspectives 114(4): 522-6. 192 allergy: evidence
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager probably the most likely one. Hygiene hypothesis modern life so we should not be saying that the originates from epidemiological data but there is also increase in the prevalence is due to a single factor; quite solid basic immunology data that would almost certainly not. support that at least part of the hygiene hypothesis— this concept that the increase in allergy is partly due Q463 Lord May of Oxford: I did ask because what to us becoming cleaner—may well be correct. Let us many of the subsequent questions are going to do is not forget that it is still a working hypothesis and not explore the fact that we do, as you have just said, tend a fact. to lead more sedentary lives in houses that are by and large less draughty and we spend less time outdoors. Q461 Lord Taverne: What I find diYcult about that Professor Custovic: Absolutely. hypothesis is that the instance of allergies generally is Dr Harrison: I would like to say that there is evidence much higher in the United Kingdom and we are not that supports the hygiene hypothesis but not every notably more hygienic than countries in continental study confirms it, so it clearly has some kind of role Europe which have a much lower rate. I can see the in the etiology. But if you think about what it means, stories that are told about the apparent correlation it is suggesting that excessive hygiene—that is between the two but does the continental experience the prevention of early life exposure to allergens/ really cast considerable doubt on that hypotheses? antigens—could have negative consequences because Professor Custovic: Let us not forget that we are the body is not able to build up its natural resources talking about the diVerences in the prevalence of to combat later exposure. That might be true for allergic disease in the developed world. We are some substances in the environment but it might not talking about shades of grey; we are talking about be true for others. In other words, early life exposure adiVerence between 23 and 27 per cent. Real to some antigens could be a good thing; early life diVerences lie between countries that are currently exposure to some others could have a negative on-going transition; real diVerences you can see in consequence later on. There are very many areas of the world like Africa, and Africa give you a confounders, as with many scientific studies, which great example of the potential role of hygiene. For make it very diYcult to quantify any one factor. example, numerous studies have demonstrated There is clearly some usefulness to the hypothesis but unequivocally that the prevalence of allergic diseases it does not explain everything. is markedly higher amongst aZuent populations which have adopted westernised lifestyle compared Q464 Lord May of Oxford: Do you think enough is to populations living in the same areas but not being spent in basic research to try to answer this adopting westernised lifestyle. That is where you see question and essentially on the basic interplay the diVerences of two to three fold rather than between the semantic construction of the immune percentage diVerences. Without any doubt there is system in the first few years of life and the not a single thing that would explain the overall environment in which it is being constructed, which incredible increase in the prevalence of allergies. We is not really a mainstream fashionable thing as I are looking at diVerent facets, at diVerent parts of a understand it in the molecular biological kinds of puzzle that we are trying to put together and hygiene studies of the immune system? may well be one of them. Dr Harrison: I am not an immunologist but maybe my colleagues can comment. Q462 Lord May of Oxford: What, if any, are the Professor Custovic: The answer in terms of investment other competing hypotheses? is that clearly not enough money has been spent. We Professor Custovic: I think we are all fairly certain are suVering from the fact that we are not in one of about the fact that the increase in the prevalence of these big identified programmes like cardiovascular allergic diseases is environmental which raises the disease or diabetes. If you look at the proportion of really beautiful question as to what is environment. I the population that is suVering from allergic diseases personally subscribe to Einstein’s definition of and respiratory diseases and the proportion of environment which is that environment is everything funding that goes towards allergic diseases and that is not me. Within this very broad description respiratory diseases you will see an incredible of environment you have hygiene or, broadly discrepancy. speaking, exposure to microbes but also another very important aspect, diet. Diet has changed Q465 Baroness Perry of Southwark: I wondered if tremendously. There is indoor environment and I am any of the studies or research there has been an sure that some of my colleagues are going to talk investigation to look at the total overload of the about indoor environment much more. There are change in the environment. It is not only the things changes in the pattern of exercise that kids have you referred to earlier but diVerent materials—we undergone. There are quite a number of aspects of wear man-made fibres; we have man-made fibres in allergy: evidence 193
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager our carpets and our sheets and our furniture and so asthma and you are not allergic to dust mite it on—and we have had huge changes in diet as has probably does not matter. The really interesting been said. Is there any evidence that if you reduce question that Dr Harrison raised was what is the role even part of that overload it decreases the incidence of the house dust mite in the development of asthma or helps the suVerer? and that is where evidence is not as strong as the one Mr Ager: Strathclyde University certainly carried out linking disease severity in patients with already research that very simple things like steam cleaning established disease. Generally speaking, allergens are furniture, changing bedding, boiling bedding and the very important in individuals who are allergic to introduction of floors like linoleum and laminate them. flooring could make a 70 per reduction in asthma attacks. This was a study done on existing families Q468 Lord Taverne: What success is there to point to and that certainly worked, just reducing dust and in attempts to eliminate house dust mites in either factors in the atmosphere. secondary or primary prevention of asthma, rhinitis Dr Harrison: In addition to allergens themselves, or eczema? constant exposure to irritant substances can provoke Dr Harrison: I would say that there has been a lot of a response to sensitisers. To answer your question, debate about this as to what practically you can do to over the last few decades there has been a vast help alleviate symptoms in people that might be increase in the use of chipboard furniture, for suVering from reactions to house dust mite. It is very example, which is constituted with formaldehyde diYcult to totally eradicate house dust mites from a resin and the formaldehyde is a well-known irritant home, but what they enjoy is warmth and moisture. substance. It is possible that that could be a factor in They like living in certain places and some of those modern housing which exacerbates a reaction to places are very important for personal exposure. For existing allergens in the environment. example, they like living in pillows and mattresses so there are very practical things that can be done to Q466 Chairman: Do you think the term “hygiene reduce exposure by eliminating or at least removing hypothesis” is a misnomer? It has also been called the either the source or exposure to the source of “jungle hypothesis”. allergens in those materials where close contact Professor Custovic: It really is a broad umbrella under occurs; but it is probably not very productive or cost which we try to carry out research to understand the eVective to believe that you can totally remove house increase not only in the prevalence of allergic diseases dust mites from a whole house, or even that you but also some other immunologically based diseases. would want to try to do that. I think it is better to be It is only one of the hypotheses as everybody stressed very focussed on the activities that are undertaken and certainly not the only one. and the eVorts that are made to reduce levels and to reduce exposure. There are certain housing features Q467 Lord Taverne: Coming to indoor factors, what which predispose a house to have high house dust evidence is there about the role that dust mites play in mite levels and those, as I said, are extended periods the development or exacerbation of allergic diseases? of warmth and dampness. Dr Harrison: Very many people are sensitive to house Mr Bryson: Could I just to add to that on the housing dust mite allergen and most homes in the UK have conditions, clearly one of the factors in this is the way house dust mites; they are essentially ubiquitous. The that older housing has been improved. In older amount and concentration of antigen obviously housing quite often what you find is that there is varies but it is ubiquitous. The fact that somebody is double-glazing put in which seals out all the drafts sensitised to house dust mite does not mean, and lack of ventilation and the increase in heat in however, that they will show any clinical symptoms. older houses but not eradicating dampness all It is a kind of three stage process: becoming sensitised contribute to the right growth conditions as well. to the substance as revealed by a skin prick test, for example, development of a bronchial response to Q469 Lord Taverne: What can we learn from the that substance and then manifestation of clinical Fairfield project? symptoms. The dose response curves for each of Mr Ager: As Paul mentioned, you cannot completely those diVerent stages is probably diVerent, so it is a get rid of dust mite and I do not think that was our very complicated scenario where you cannot easily intention; it would be impossible to create a sanitised predict whether a particular exposure is going to have environment where there would be no dust mites a particular eVect in a particular individual. present. The features we majored on where trying to Professor Custovic: I would absolutely agree with that. control the environment within the houses to keep Generally speaking, to simplify it, if you are allergic the heat and moisture at a level where dust mites to house dust mite, if you have asthma, then exposure would not produce as much. That was done mainly to house dust mite is not a good idea. If you have by looking various strategies, mainly ventilation for 194 allergy: evidence
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager cleaning the air in the house, creating, if you like, a because a lot of studies are confounded by the simple sponge eVect wall which took water out. In older fact that we have drawn patients who have had the housing it is easier to describe. Damp would sit on disease for 20 or 30 years. They could have started walls or windows and water is taken away which with allergy but by the end of this long process the reduces the environment so that the dust mites allergy is not the only—and certainly not the main— cannot breed. It certainly worked and it is becoming reason for the perpetuation of the disease. The more and more common in housing where breathing message is, identify individuals early and reduce walls, as they are called, are used. exposure substantially if there is going to be a benefit.
Q470 Lord Taverne: Is there any conflict between the Q472 Lord Colwyn: Moving on to other allergens, low energy approach and the elimination of dust we are aware that there is a wide range of fungal and mites in the sense that you need more ventilation? bacterial species which can be isolated from indoor Mr Ager: I think the building sector has become very air. Is there evidence that specific moulds, fungi and focussed on energy and creating airtight boxes that bacteria can trigger sensitivity and allergic diseases are easy to heat and reduce energy costs but the other such as asthma, rhinitis or eczema? cost has been indoor air quality which is not focussed Dr Harrison: There is a diVerence between biological on as much. We have become obsessed with as cheap allergic responses and responses that individuals can heat as possible and creating, if you like, vacuums show which do not have, at least at the present time, where people spend 90 per cent of their lives and the biological explanations—these are the sensitivities or air quality in the modern homes is not high. intolerances that individuals specifically show. To answer your question, the evidence that I reviewed— Q471 Chairman: What is the evidence for the specific a few years ago now, admittedly—showed very link between house dust mite and eczema? clearly that children in damp and mouldy homes have Professor Custovic: Probably the best house dust mite self-reported symptoms of respiratory disease. When allergen avoidance trial comes from eczema rather measurement is made of specific mould species it is than from asthma carried out by Peter Friedman in not possible to relate any one particular mould, for Liverpool about a decade ago, probably one of the example, or certainly bacteria, to the outcome. That very, very few clear, simple mite allergen avoidance is because it is, in any case, a mixed exposure that studies showing unequivocal beneficial eVect. I really people are having. Moulds and bacteria consist not would like to draw a parallel here between what only of the antigenic properties but also they might we are talking about—asthma, allergic rhinitis or produce toxic metabolites and components of their eczema in a community—with occupational allergic cell walls can induce a response. There is a kind of disease. Occupational allergic disease gives us a mixed medium, if you like, of potential insults to an beautiful example as to what actually may be going individual’s health. Apart from possibly Alternaria on, an individual getting into a situation of a novel species, where there have been studies that show a exposure (be it in a laboratory with rats or whichever) specific risk factor from exposure to those moulds, developing sensitisation and then soon after generally speaking the evidence shows the connection symptoms of allergic disease. The treatment of choice between damp and mould generally rather than with is removal of that individual from the exposure specific species. situation. Providing we remove the patient quickly, providing the diagnosis is established early in the Q473 Chairman: Am I correct that Alternaria is natural history of the disease, we have a potential for associated with asthma but not rhinitis? cure. If the patient is left in this occupational Dr Harrison: I do not know that. environment exposed to sensitising allergens for a Professor Custovic: That is correct, moreover it is long period of time, even complete cessation of associated with very severe asthma and with asthma exposure will not result in the improvement of deaths. In the UK what we have is a fairly clear the disease because the disease becomes a self- association between sensitisation to moulds and perpetuating process. This really teaches us several asthma severity. Sensitisation to moulds is very important lessons. If we are going to try to overwhelmingly present amongst individuals with address the disease by environmental control then we very severe asthma. have to develop methods to reduce exposure very, very substantially. We can send patients to Q474 Lord Colwyn: I gather that penicillin is often Switzerland and they improve but we need to do found in this air; might that be associated with something about creating that sort of environment in penicillin sensitive reactions? How do you relate the our homes. That is one challenge. The other exposure to small amounts against something like challenge is identifying patients who may benefit peanut allergy where we are beginning to find out early enough in the natural history of the disease that exposure to small amounts of peanut might allergy: evidence 195
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager ameliorate a more severe reaction as the child gets Mr Ager: They are not prohibitive in cost. A heat older? exchanger would be about £350; installation is Professor Custovic: That is a very diVerent context of slightly more. the route of exposure, one being inhaled and another Mr Bryson: Could I just add that the types one being ingested. Really for development of oral of householders that environmental health tolerance you need a higher dose of exposure, but practitioners meet very often have no money at all. If that is a slightly diVerent context and I would not you try to explain to them that trying to control really like to embark down that road. I think the condensation, dampness and mould is partly within problem that we have with moulds is our inability to their own hands, that is a very diYcult concept to put measure exposure appropriately. The whole of the across them. What they want to find is a simple cause research into dust mite has been empowered by the for it. It is not about the way they use the heating and fact that we can accurately quantify exposure and ventilation. As was mentioned, the educational side like any science the ability to measure created a whole of it is a very big thing, to try to educate people on V range of studies looking into association between this. For a lot of the people who su er those exposure and response. With mould and fungi our conditions, the prospects of even spending £300 ability to measure is still very, very poor. would be impossible; we are talking about people at Dr Harrison: I think there is a better correlation the very bottom of the housing market. between an observation of damp and mould in a house and symptoms than there is between measured Q477 Chairman: Can I go back for a moment to levels, and that might reflect just the fact that we do mould exposure because we live in a climate with high not have the technology to properly measure these environmental humidity, but as far as I understand it things, or it might reflect the fact that it is not the some of these studies have been done in parts of the mould per se but the whole environment. If a house US where the atmosphere is very dry. I wonder if is damp and mouldy it implies that it is poorly heated there are problems transposing across and also, if you and poorly ventilated which means that exposure to are looking at mould exposure, whether detection of other pollutants is likely to be higher as well, so there IgG and possibly IgE would give you an idea of V are many confounders in that sense. exposure to di erent moulds. Professor Custovic: You are asking all the right questions and we do not have answers to most of Q475 Lord Colwyn: Does that answer my question them. Certainly the work on alternaria has been done as to how these eVects can be controlled? predominantly in Tucson because it is big, it is Dr Harrison: I would also urge more public education seasonable, et cetera, beautifully reproduced by Jon about ventilation. The question was raised about Ayres in Birmingham. Asthma is in part due to energy use; it will not diminish of course and will exposure to pollen, in part due to exposure to fungal probably increase the push to reduce energy particles. There is very little doubt about the fact that consumption. There are ways of balancing it, potentially fungal exposure may be important, but although it is a conflict between fresh air—possibly until we can assess not only the biological eVect of cold fresh air—and keeping a house warm. I think exposure but also measure exposure it will be very, Y even in more modern housing where ventilation is very di cult to make a dose response curve trying to V appropriately supplied people do not tend to like estimate the e ect of exposure on any of the draughts and they will often stop up any ventilation outcomes. Let us not forget that it may as well be bricks that they have in the home because they do not pretty non-specific; they may act as adjuvants, they know that there is any dis-benefit of doing so. I think may act as irritants; we simply do not know. What we there is an element of education about informing do know is that in all the epidemiology the people that maintaining natural ventilation in their association between them and mouldy houses is much more than the association between dust mite home as well as working to reduce exposure from and asthma. The fact of mouldy homes overwhelms particular sources is important. the eVect of dust mites alone. The strongest evidence of that probably comes from Holland and I would Q476 Lord Rea: Is the answer not to make greater put to you that their climate is pretty close to ours use of heat exchanger mechanisms such as we have in and that is where the real strong body of evidence Portcullis House here and is used in the Beddington comes from. Zero Energy Development (BedZED) where the air that comes in is heated by the air that goes out by Q478 Viscount Simon: What impact do pollutants, contraptions on the roof. I imagine they are probably such as airborne particles, carbon monoxide, rather expensive but if it were widely used maybe the formaldehyde, pesticides and cleaning agents have on cost would come down. allergic diseases? 196 allergy: evidence
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager
Dr Harrison: I alluded before to the fact that exposure NO2 and allergen exposure (house dust mite to substances in the home can exacerbate the and other allergens), which has been tested responses to allergen exposures. I mentioned experimentally. Unflued appliances in the home are formaldehyde because it is a well known respiratory generally a bad thing I think. irritant and sensitiser in its own right. I think people tend to be worried, for example, about low levels of Q479 Viscount Simon: Are you aware of any pesticides but they do not seem to be so concerned research being done into the eVects of chemicals in, about the liberal use of bleach and ammonia. A let us say, woodworm and dry rot treatments, fly personal thought that I have is that individuals who papers (the things that hang up), plug in air are exposing themselves to levels of ammonia and fresheners and fabric conditioners? If research is bleach, for example, that could actually irritate the taking place, do you know who it is being done by? respiratory system, could well be making themselves Dr Harrison: The question of research into consumer more susceptible to allergic insults. I think there is a products has been left behind a little bit. There have role for chemicals in that sense and a role possibly in been scares recently about the use of air fresheners the sense that some might be responsible for so-called and children’s health in the home and causing multiple chemical sensitivity or idiopathic chemical migraines in mothers. It is rather speculative work; it sensitivity. In terms of biological allergenicity it is is a rather Cinderella subject and requires a little bit really those irritant substances that are going to be more focus. most important. Professor Custovic: I think the evidence is pretty Q480 Chairman: What about the Bristol study unequivocal that if you are asthmatic or if you are a where they are monitoring children long term? patient with established allergic disease exposure to a Professor Custovic: The Bristol study is one of a whole high level of indoor air pollution may make your range of prospective birth cohort studies. We are disease worse. Whether it will cause it per se is much extremely fortuitous in the UK to have probably the more diYcult and much less clear. The evidence up best prospective birth cohort studies which are until now is probably against. There is also quite an currently, for the first time, all acting together as interesting body of evidence mounting on the a consortium trying to understand these very potential role of outdoor air pollution if we can important questions. Five major British birth cohort diVerentiate between the two, for example the way studies—Bristol, Manchester, Aberdeen, Kent and potentially diesel exhaust particles actually aVect Isle of Wight—have agree to work together in order pollen grains and pollen allergens making them more to try to answer these very important questions. The allergenic. I think probably what we have done for real problem of course is the multitude of exposures, ease of our understanding for years is to be obsessed very few of them being independent of each other and with single issues; we went from house dust mite to trying to tease out what exactly is the role of one as fungi to pets. In reality our patients are exposed in opposed to another is sometimes not easy. It is very their own homes and in their outdoor environments much like a diet: is it vitamin C or is it eating an apple to a soup of diVerent allergens and diVerent irritants that is good remains quite interesting as a concept. and diVerent viruses on top of them. All of these exposures interact with each other giving you the Q481 Baroness Platt of Writtle: Do current building final eVect. There are beautiful studies now showing regulations adequately take into account the needs of unequivocally that there is interaction between allergy suVerers in the home? indoor air pollutants and viruses; interaction Mr Ager: No, there is no policy that I am aware of in between viruses and allergens; interactions between building regulations on the use of formaldehyde or allergens and indoor air pollutants. It is part of chemicals used in insulation or gas cookers and there a complex picture in which various allergens is no regulation which covers air quality within the and irritants probably synergistically act upon home. Certainly in Scotland housing that social individuals with diVerent susceptibilities to various landlords build has to be barrier free to standard. environmental triggers. What is suYcient to put Arguably you could include air quality within that somebody in hospital will hardly be noticed by but it is not in there at the moment, it is more for another patient. That does not mean it is not physical disability. important. Mr Bryson: The building regulations are a minimum Dr Harrison: I think historically something like 60 per building standard so they are the basic minimum. cent of British homes have a gas cooker, an unflued There are two things about that really, one is that appliance which is liberating nitrogen dioxide and they only apply to new dwellings or conversions; they formaldehyde, for example, into the air. I think that do not extend to existing buildings so they cannot be is something which could also be important. There applied to those as well. Bearing in mind the length of have been studies showing the interaction between time that houses currently standing will have to allergy: evidence 197
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager remain occupied, the recurrent rate of replacement is Q484 Baroness Perry of Southwark: Forty per cent about a thousand years. of the population does suVer from some kind of allergy and that is a lot of purchasers who do care about it. Q482 Baroness Platt of Writtle: Are there any ways Mr Ager: That is true but there is this sort of in which you think these regulations could be dichotomy in the realms of aVordable housing and I improved to control exposure to allergens and other am not sure of the value personally. pollutants more stringently? Of course you have just Mr Bryson: I think the introduction of the house mentioned older houses, particularly in that context. condition report in the home information pack is Dr Harrison: It is very diYcult through building voluntary at the moment and there seems to be some regulations alone and ventilation requirements alone question as to whether it will be made compulsory. I to make a big impact because of the vast proportion think that is unfortunate personally. Averages, as of existing housing that cannot be easily remedied. I ever, do not tell the true story; there are a lot of know there is a lot of science that goes into the people who live in the same dwelling for many, many establishment of the ventilation requirements and I years so a house condition report would be of limited would not criticise that. I just think there is a limit value to them. On the sale of houses, of course, to what can be achieved through the building people are more interested in the value and the cost regulations. than they are the condition. Mr Ager: In Norway there is an allergy specification included within building regulations and standards Q485 Baroness Perry of Southwark: Is there also a but again that applies to new build and not what is tension between the building itself and the contents there at the moment. which the people bring with them? From what you Dr Harrison: I think there is an option for looking at were saying most of the house dust mites would be labelling and emission standards for building residing in the furnishings rather than in the building products and materials so that materials used in so they would bring their own house dust mites with homes are not high emitters of potentially polluting them in their beds and pillows. substances like formaldehyde. There are standards in Mr Ager: Arguably that is true. As I said before, existence but I think more could be done to you can have the cleanest house and controlled encourage the use of cleaner materials in that sense environment but when you walk in you pollute it and lower emitting substances and lower emitting immediately. If you bring in furniture you pollute it appliances used in the home. immediately. That reinforces what I was saying Mr Ager: We would support that but it is actually earlier. quite hard to source materials in the building centre Dr Harrison: The behaviour of the occupants has a at the moment to meet needs. For fourteen units we large impact on the conditions inside a house. could not source the materials so the supply is not there at the moment. It can be there but it is very Q486 Earl of Selborne: Is there a role for the expensive. Government to issue guidelines to the public on either how to reduce the risk of developing allergic diseases or minimising their aggravation by Q483 Baroness Perry of Southwark: Returning to substances in the home or changes in lifestyle? Would the issue of existing housing stock, there is now a it be feasible for the Government to oVer such advice? requirement when you are selling your house to have Dr Harrison: I think so. I once worked in what was a survey done yourself and passed on and I know then the Department of the Environment in the there has been some discussion that that might indoor air quality branch and I actually addressed the Y include, for example, tests for energy e ciency for question of setting guidelines. That was some 13 your house so that the person purchasing it is warned years ago I think and last year or the year before the they are buying a house which is not very energy Committee on the Medical EVects of Air Pollutants Y e cient. Would you see a case in the future did produce a document which is called Guidelines for for including the allergy count of your house? Indoor Air Quality (or something to that eVect). It Apparently houses on average change hands every deals with a number of chemical or gaseous seven years so you soon begin to tackle the existing pollutants in the home and it suggests guideline housing stock. values which line up very much with the WHO Mr Ager: Personally I am not sure of the value in that standards. It also suggests behaviours that would because unfortunately it does not drive people when help improve indoor air quality. Unfortunately that they are buying a property. Energy eYciency will but document has not been very widely circulated and unless you have someone within your family who has accessed. It remains on the DH web site but I do not an allergy or asthma I do not think it is a selling point. think enough people have seen it and I think it is a 198 allergy: evidence
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager good starting point to Lord Selborne’s question on air quality. There were four relatively simple about really giving good guidance to individuals features in the house which you do not really see. The about what they can practically do to improve their most crucial thing was moisture management own situation. creating an environment that dust mites could not breed in by use of various ventilation strategies, your Q487 Earl of Selborne: Dr Harrison and I have both normal trickle strategies and fans, mechanical heat at one time sat on the Chemical Stakeholder Forum recovery methods and we also did five with the which was to try to identify chemicals in general use breathing wall method and the breathing ceiling to or in the environment which might be toxic or bio- create an environment where dust mites find it cumulative or persistent in one form or another. One diYcult to breed. We completely avoided gas heating of the issues which is mentioned in the Fairfield study and gas cooking (so no naked flame or appliance is that the resin which is most benign for sticking lino within the home). There were two reasons for that, down was available in Holland but not in this electricity being more sustainable and the fact of the country. Is there not an issue here that we are not evidence of naked flames, central heating and gas making available some of these benign materials for cookers do have an impact on allergy suVerers. We some reason? worked to non-toxic specifications where possible Mr Ager: I do not think the market is fully developed and we tried to look at taking out formaldehyde, for them yet. In the UK there is not a market for toxic materials and preservatives where possible. We them. The Fairfield project is now four years old; avoided Upvc windows and went for wooden there has not been a project to replicate it repeated in windows because they do not have as much chemical the UK to my knowledge. Certainly some of the content in them. More importantly, within the factors that were put within the project have been buildings themselves, we sourced linoleum floor used but there is not a huge market for them. There covering for tenants who wanted that and we spent a is no incentive for private developers. They will great deal of time with the people going into the produce energy eYcient housing but there is no houses as an education as to how to use the house incentive for them to enhance air quality. The properly. In terms of features, to walk in you would materials are not there at the moment. Perhaps the not think there were any diVerent features from a Government has a role in looking at that. normal home but they are there.
Q488 Earl of Selborne: This seems to be a market Q490 Baroness Perry of Southwark: Was it failure. If this would be even a modest help should we expensive to produce that? not try to encourage the building industry and do-it- Mr Ager: Arguably at the time it was but the cost yourself stockists to take it more seriously. today probably not. When you do a pilot the building Mr Ager: Possibly, yes. industry is slightly nervous of what you are trying to Dr Harrison: There has been an advance in the do but the more you do it the easier it becomes. I do production of low VOC emitting paints and not think it was hugely expensive to do that. companies like B&Q created a symbol which they put on their products to encourage the use of low VOC Q491 Baroness Perry of Southwark: Are there emitting products and I think more can be done in several projects of this kind or is it fairly rare still? that way. The use of symbols and labels as well as Mr Ager: We were the first in the UK; I believe there possibly other regulations to encourage the is one other one in London but I am not sure where. manufacture and use of low emitting products may We have not tried to replicate a new build of what be of use. was done there completely. We have used the Professor Custovic: That is very, very similar to the mechanical ventilation strategies and again the way the food labelling is going towards identifying paints. Going back to refurbishment of existing what may be the healthy option; I stress what may be property, we have refurbished a small number of flats the healthy option. We pretty much know what good taking into account the principles we used, using a indoor air quality is without going into details. non-toxic specification.
Q489 Baroness Perry of Southwark: When we talk Q492 Lord Rea: What is the evidence that living in a about aVordable low allergy housing, what exactly low allergy house has an eVect on either the allergic are we describing? Can you give us some of the sensitisation or aggravation of existing allergies? features that would be found and what special Mr Ager: The research was, like a lot of things, adaptations such houses would have? inconclusive. It showed that the quality of the air Mr Ager: A dwelling that was designed avoiding within the home was increased quite substantially where possible known pollutants or irritants to between the three diVerent types. It was something allergies at that present time and obviously focussing like five to six per cent better in the houses with the allergy: evidence 199
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager ventilation strategies rather than the conventional housing stock and existing problems that are already house type. We did have the feel good factor with there? Again, arguably, most people within social people within those houses; certainly people with housing just want to be able to heat their home asthma felt better and their reliance on inhalers and eYciently without anything else on top of that, so other medication decreased. However, I do not think there is a big challenge there to be tackled as well. the sample was big enough to give a conclusive Dr Harrison: Yes, I would agree. I think that heating answer. There was a slight improvement but you and ventilation is important. Also I think to not use would need to do it over a much larger scale to look substances which emit formaldehyde would be a at it properly. good idea and to educate people in the way to manage their home so it does not build up high levels Q493 Lord Rea: The change is suYcient to warrant of house dust mites and mould would be a good at least the builders and the occupants thinking that thing. it was worthwhile. Professor Custovic: We have to stress that probably Mr Ager: Yes, definitely. Going back to what one of the emphasis on the term low allergen housing is my colleagues said about the age of people and wrong because what we are talking about is healthy allergies, the people in here generally are older and indoor environment. Pretty much like healthy eating the disease is well developed and, as I said, they options you have healthy indoor environment. I showed significant improvement because of the air think that by and large allergens are probably the quality within the home. least important part of the overall concept of healthy Dr Harrison: I would say that this is a very good idea indoor environment. but it should not be seen as a panacea. I do not think it should be expected, almost miraculously, by living Q495 Lord Rea: What needs to be done to the in a house like this that all your problems will current building regulations to ensure that houses disappear. It is certainly the case with allergic that are built in the future conform to these sensitisation that very often people who do not get specifications? allergic to house dust mite will get allergic to Dr Harrison: There are ideas put forward by the something else, if they are susceptible to that. I think Building Research Establishment (BRE) about in terms of well-being it is a very good idea to have healthy housing schemes. I do not know the details of these houses built with low emitting substances, those but I would suggest they were well thought out certainly good ventilation, heat recovery et cetera, and worthy of consideration as to optimal design for but all the studies that have been done that I new houses. Whether some or all of that should or know about have struggled to show a statistical could be built in with the building regulations I do improvement over a prolonged period of time and not know. where, in the extreme case in Scandinavia, homes Mr Ager: Certainly air quality management could be have been built with no man-made materials at all in built in but, as John said, building regulations are the hope that people who suVer from chemical very basic at the moment and that is quite an sensitivity will have a better life, this has often failed advanced step forward. because wood emits turpines and other volatile Mr Bryson: The building regulations react to materials which are similar to the chemicals that are development in construction in actual fact rather present in man-made substances. Just because than lead the way. something is natural does not mean to say it is not potentially toxic. We have to be careful in making Q496 Lord Colwyn: You have ruled out the use of assumptions about the benefit of such housing, gas. Assuming you agree it is not a brilliant idea to although it is clearly not a bad thing. live underneath power cables, can you say whether you believe that modern electronics—heaters, TVs, Q494 Lord Rea: From the comments you have just microwaves, computer screens—have any eVect given I can probably guess what your answer will be on the immune system and then possibly the to my next question which is whether you think that introduction of allergic disease? Do we still hear low allergy specification should be incorporated into about sick building syndrome? Is there such a thing the design of all new housing and, to add to that, as that? major refurbishment of older property requiring Professor Custovic: Oh yes. planning permission. Dr Harrison: Certainly there is. Although nobody can Mr Ager: I do agree with Paul that it is not the magic say what causes it there have been various ideas. answer but certain factors should be considered. The There was an interesting study done on microwaves mechanical heat ventilation recovery systems are an which nobody could quite understand. It might not excellent way forward. However, there is the big have been to do with the microwave but to do with question, how do you track back and tackle existing the diet that the people were eating, using the 200 allergy: evidence
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager microwave to cook their food. Again it is very us the disease. The real tricky concept of all of that is diYcult to tease out causative factors. that in the long term it may well be that in order to Professor Custovic: I will step away from what I prevent allergy we will have to remove house dust believe (because I kind of struggle with the concept of mites or to add house dust mites or to remove belief being part of an inquiry into what the evidence microbes or to add a little bit of microbes. Each is); I do not think there is any evidence for the time intervention is going to be specific for specific being. individuals at risk. I think that is the way to go. The way is to go in a much cleverer, holistic medicine way. Q497 Chairman: Mr Bryson, you very helpfully gave We will appreciate and understand the individual us some additional information which we have tabled susceptibilities of our patients and not look at them today for the Committee and in it you point out that as mean patients derived from clinical studies. the Chartered Institute of Environmental Health has formed a commission on housing renewal and public Q499 Chairman: From the non-clinicians’ view health and that the commission recommends that the point? guidance on neighbourhood renewal assessment is Dr Harrison: I think that unfortunately interventions revised to include a health impact assessment on the which seemed a very good idea at the time sometimes diVerent options for action. I wondered how you just do not work and then people rub their chins and envisaged this actually happening. wonder what went wrong. It is because we do not Mr Bryson: What the commission found was that a understand everything that is happening in the cause- lot of the emphasis in actual fact was partly on eVect chain. To answer your question, it seems to me housing condition but predominantly it was about that there are interesting impacts of exposure at economic factors and social factors and in their diVerent stages in life and it would be very useful to submissions to the commission hardly any of them understand a bit better the important windows of was a health assessment part of it. There was no exposure through one’s lifespan which are important particular assessment of that. The final report has not for diVerent aspects of the environment we are been produced but in the interim report the exposed to. That I think would be a good focus for recommendation is that that could be part. There is research. what is described as a Neighbourhood Renewal Mr Bryson: Obviously I am not qualified on the Assessment Manual which is provided by the medical side. All I would say is that while any further Department of Communities. It would not be research is taking place what is important from our diYcult to introduce a health impact assessment into point of view is that indoor air quality is improved that. In our submission to the sub-committee, I think and housing conditions are improved because quite we also point to the work that has been done on clearly it is not improving people’s health living in SheYeld Homes to show the beneficial eVects that damp conditions and conditions where allergens can be produced by linking housing and health. At can thrive. the moment our view is that there is an inadequate Mr Ager: I would not disagree with that. As a total link between the two. non-clinician, I think we can get carried away with some of these allergy projects. It does add value but Q498 Chairman: Given that we understand that the I think what is important is to research how we can development of allergic diseases is determined by the improve existing homes to improve air quality. The interaction of genetic and environmental factors, I knowledge is there for new build homes but it is wondered what each of you feel is the main future looking back which is the predominant stock in this thrust for research into environmental factors country, and how people modernise and improve. I associated with allergic disease and where the think research should be focussed there. research energy should go. Professor Custovic: I firmly believe that the day and Q500 Chairman: Earlier on, Mr Bryson, you spoke age of simple public health advice where something is about the group of the population who are living in good for everybody is over. We are diVerent poor socio-economic conditions and the diYculty of individuals. What is very good for me may not educating them to adjust their lifestyle. I wonder if necessarily work for you or may indeed really be bad you have any more comments to add to that. for somebody else. We need to move away from the Mr Bryson: I think one of your colleagues mentioned concept of one size fits all and that is in terms of about possible incentives to do that. Unfortunately intervention, in terms of drugs, to very targeted we live in a world where often people need some sort interventions aiming to make a diVerence in of incentive and unless it is possible to explain to susceptible individuals. In order to develop that we them the direct health benefits, some other incentive have to ultimately understand how environmental may be required to try to put the message across. I factors interact with genetic predisposition in giving would never suggest it is easy, but at the moment I am allergy: evidence 201
7 February 2007 Mr John Bryson, Professor Adnan Custovic, Dr Paul Harrison and Mr Grant Ager not sure there is enough eVort being put into that to believe we will prevent allergies? I most sincerely try to make sure that people can help themselves to a hope so because that is what we have devoted our certain extent. careers to do. It will come too late for the 15 million people who have the disease now and what are we Q501 Chairman: If we look at the concepts of genetic going to do about that now? and environmental interactions and research do you Mr Bryson: Could I partly echo what Professor think eventually we will see a turnaround or even Custovic has just said? It does not go down very well prevention of allergic diseases? with colleagues when you say that ultimately you Professor Custovic: My aim as a physician is to make want to reduce the number of them that are required, physicians obsolete; that is what we are there for. but that is also part of our philosophy: prevention is Then my career would be fulfilled. Yes, we will get far better than cure and some of the work that we there but if we stop allergies today there will still be a want to try to do is to prevent those situations rather lot of patients for the next 30 to 40 years and the real than constantly be on the curative side. tragedy of today is this little rule of numbers: we have Chairman: Can I thank you all very much indeed for a conservative estimate of 15 million patients; we having come today to give evidence to us. You will be have an optimistic estimate of 24.9 allergists in the sent a transcript in draft form for you to correct if country. That is a real, real scandal and tragedy of necessary and if there is other information you think our situation. Our patients need to live three the Committee may find helpful after today then thousand years in order to be able to see allergists. If please do send it in and we can circulate it to the there is something we could do now, we could make Committee as part of your evidence from today. a big diVerence in a very short period of time. Do I Thank you very much indeed. 202 allergy: evidence
WEDNESDAY 21 FEBRUARY 2007
Present Broers, L Platt of Writtle, B Colwyn, L Rea, L Finlay of Llandaff, B Selborne, E (Chairman) Simon, V Haskel, L Taverne, L Perry of Southwark, B
Memorandum by The Society of Homeopaths
1. Summary 1.1 Homeopathy is a safe, eVectual and cost-eVective form of medicine for the treatment of a range of allergic responses, increasingly being sought particularly by parents with young children. Indeed, for many parents facing the prospect of steroidal treatments, homeopathy is the treatment of choice. Yet, despite the growing demand for homeopathic treatment, access remains extremely limited for families and individuals who cannot pay and do not have access to private medical insurance. 1.2 The Society of Homeopaths would particularly encourage the Government to introduce measures to make homeopathy more available to patients suVering from allergies, on the NHS. In particular, the Society calls on the Government to send a stronger signal to primary care organisations that homeopathy has an excellent evidence-base in this area and to give them permission to refer patients to registered homeopaths (RSHom) for treatment.
2. The Society of Homeopaths 2.1 The Society of Homeopaths is the largest and most representative body for professional homeopaths in the UK. We have 1,500 members on our Register, most of whom have completed recognised courses and have undergone at least one year’s supervised clinical practice and a six-month CPD-based registration process. Our Registered Members are subject to a rigorous Code of Ethics and are insured to £3 million professional indemnity. The Society’s development as a professional organisation was commended by the House of Lords Select Committee’s report on Complementary and Alternative Medicine in 2000, which states, “under The Society of Homeopaths, the non-medical homeopaths have organised themselves well and their professional organisation should mean the transition to statutory regulation does not present too great an upheaval.” 2.2 Our Registered Members increasingly engage with health professionals such as doctors and nurses in providing complementary care for allergy suVerers. Where homeopathy is provided on the NHS (Wiltshire, Yorkshire, Nottingham and London) patient opinion surveys consistently reveal high satisfaction with the service.
Defining the Problem
3. The homeopathic approach to allergies 3.1 The homeopathic approach to the treatment of allergy entails a full assessment of the patient and takes into account hereditary features (chronic allergic patients tend to have a family history), allergic “triggers” and factors aVecting their symptoms. Treatment aims to boost the immune system, reduce toxicity within the body, and provide symptom management of acute flare-ups. Homeopathic medicines are taken internally as pillules or liquids for short periods; some homeopathic preparations are also applied topically (eg Calendula cream for eczema). Dietary and/or lifestyle advice may be given. 3.2 Homeopaths believe the incidence of allergy and allergic diseases is rising owing to a lower immune function in more individuals. This is probably brought about by a variety of factors that could be considered “triggers”: toxins in the environment; diets poor in unrefined foodstuVs and rich in additives; and possibly the over-vaccination of very young children before inherent immunity has developed. allergy: evidence 203
21 February 2007
4. Treatment and management with homeopathy
4.1 Homeopathy is a safe, gentle yet highly eVective system of medicine, frequently used to treat allergies. Owing to the high dilutions used, homeopathy is safe to use in small children and in acute situations (attacks), unlike some conventional medicines which may cause unacceptable side-eVects or an unacceptable risk to long-term health. 4.2 Evidence has shown that homeopathy can be a useful intervention in the treatment of acute and chronic allergies: — eczema; — asthma; — allergic perennial rhinitis; and — hayfever. 4.3 Parents of small children are increasingly choosing homeopathy owing to their concerns about the suppressive treatments generally prescribed for eczema and asthma, often involving repeated use of steroidal preparations and antibiotics to combat complications of the disorder. 4.4 In addition to being a safe, eVective, and cheap method of treatment, homeopathy helps patients and their carers to feel more involved in their progress to health. Patients are equally able to manage their allergies with homeopathy. 4.5 Whilst there has been some good research undertaken into the treatment of allergies with homeopathy, but The Society of Homeopaths would urge the Government to consider more research in this area a priority. We believe there would be a high degree of compliance for such research from health professionals in the field. 4.6 Whilst we would encourage more research into the eYcacy of homeopathy, particularly for allergies, it is imperative that such research is designed with the principles of homeopathy in mind. Often research into our modality to date has relied on inappropriately designed trials. Real-life clinical trials and in-practice pilots oVer suitable models to explore the role of homeopathy within an integrated healthcare system. Government-funded research carried out by Dr Weatherly-Jones RSHom (University of SheYeld) to develop relevant research models for homeopathic treatment is important in helping to inform the design of future trials.
Patient and Consumer Issues
5. Choice in Healthcare
5.1 In the NHS Plan the Government set out a new vision for the National Health Service—a health service designed around the patient. With 25 per cent of the population registering their interest in seeing complementary therapies on the NHS, the provision of homeopathic treatment in the area of allergies, will go some way to meeting patient choice. 5.2 It is estimated that 470,700 adults use homeopathy annually, spending over £30 million per year. This growing market for homeopathy is being recognised by the private sector. Private Medical Insurance companies, for example, increasingly allow referrals and self-referral to Registered Members of the Society of Homeopaths. Royal Sun Alliance, The Hospital Saturday Association, Health Shield, Healthsure, Anglia Healthcare and Civil Service and Employees Health Insurance schemes, all cover such referrals. 5.3 As the former Secretary of State for Health acknowledged in his speech to the Social Market Foundation in April 2003, patient choice has historically been the preserve of the wealthy. As Alan Milburn stated, “For too long choice in health care has only ever been available those with the means to pay for it. Those with more money have been able to exercise more choice. That is the real two-tier health care in our country.” This is true not only of conventional medicine, where patients are able to jump queues to access faster treatment, but also in complementary medicine, which remains to a large extent the reserve of those able to pay for it. Currently the vast majority of patients who want to use homeopathy to manage their allergies have to pay privately for treatment. A private course of treatment costs anything between £100 and £300. 204 allergy: evidence
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6. Barriers to Choice of Homeopathic Treatment
6.1 In December 2001 the Secretary of State for Health announced that complementary therapies that can demonstrate proof of eVectiveness will be made available on the NHS. Yet, in our members’ experience, patients are still finding it diYcult to access homeopathy on the NHS. PCTs in particular are still not referring patients to registered homeopaths even where evidence exists. The Society believes that there remain some significant barriers that prevent referrals to homeopathy. 6.2 “Permission”: The reluctance of GPs in particular to refer patients to a registered homeopath does not appear to be a consequence of personal beliefs in the eVectiveness or not of the treatment. Rather, our members have found that the key issues are simply that they do not have a history of doing so and are not being encouraged to by the PCTs. Despite the announcement by the Secretary of State that complementary medicine should be available to those who want it, many GPs appear to be under the impression that their own PCT would not allow it. 6.3 The Society is therefore calling on the Government to send a stronger signal to primary care providers that referring patients to registered homeopaths is “permitted” within the NHS. 6.4 Understanding of homeopathy amongst NHS practitioners: If patients are to exercise their choice, they need to be made fully aware of all of the options available to them. Yet, too few doctors, nurses and midwives themselves are familiar with how complementary medicines can benefit allergic patients. The House of Lords Select Committee, in its report on Complementary and Alternative Medicine, expressed concern about this lack of awareness, stating: “We were concerned to hear that, unlike the medical schools, there seems to be little or no evidence of a trend within nursing schools to ensure that student nurses come into contact with the main issues connected to the practice of CAM therapies. This is despite the fact that nurses are probably the most likely of all conventional health practitioners to use CAM techniques in their day-to-day practice”. 6.5 Financial Resources: In our members’ experience, NHS managers sometimes claim that they simply do not have the resources to fund complementary medicines as well as conventional. However, research undertaken in a number of pilot projects indicates that referring patients to registered homeopaths can help to alleviate the burdens on GPs, including the financial pressures. Case studies produced as part of a study in Bradford-on-Avon, for example, show that the cost diVerences between treating a patient with conventional medicine and homeopathic therapies can be significant for a GPs’ practice. 6.6 In order to assess the cost implications of giving patients access to complementary medicine in more detail, the Society calls on the Government to fund a number of pilot projects across the country, incorporating general medical practices, as well as NHS allergy clinics. 6.7 Regulation: A further reason given by NHS managers refusing to refer patients to complementary medicine therapists is that they believe that the quality control and regulation of the sector is insuYcient. The Society of Homeopaths is working hard to raise the standards of professionalism in homeopathy and the complementary medicine sector. The Society is a key player in the Council of Organisations Registering Homeopaths (CORH), working to establish a single register for the profession. This will enable all patients who require homeopathic treatment, as well as GPs and midwives who refer their patients to a Registered homeopath, to be sure of the professional standards, competency and accountability of the homeopaths they employ. We believe that it is essential that the new single register sets the highest possible standards for professional homeopaths and we will be supporting the most rigorous options for the development of this register.
References [not printed]
Letter from Professor Chris Corrigan, Professor of Asthma, Allergy & Respiratory Science and Consultant Physician, Guys Hospital I am pleased to submit written evidence for this Committee in my capacity as Consultant Allergist and Researcher at Guy’s Hospital, London, which is one of the biggest NHS centres for treatment of allergic disease in the UK, as Educational Supervisor to two allergy SpR trainees, as Secretary of the Joint Committee on Higher Medical Training Specialist Advisory Committee on Allergy and as counsel member of the British Society for Allergy and Clinical Immunology, the professional body for clinical and non-clinical doctors and allied health and other scientific professionals working in the field of allergy. allergy: evidence 205
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Defining the Problem Allergic diseases represent a particular class of immunological “hypersensitivity” reactions (“hypersensitivity” reactions are immunological responses produced in certain persons which, instead of being advantageous to the person, such as in fighting oV infections, are actually harmful by causing tissue damage, disruption of vital organ function and even death). Allergic hypersensitivity reactions occur because certain individuals have a propensity to produce an allergic antibody called IgE, which recognises external foreign proteins which find their way to the mucosal surfaces of the skin, airways or bowels of predisposed patients. The particular proteins which set oV these responses are collectively called “allergens”. It is not known why some individuals make IgE antibodies to allergens whereas others do not, even though everyone is exposed to a broadly similar range of allergens by breathing them in or swallowing them. Once the allergic IgE antibodies are formed, they coat the surfaces of special inflammatory cells in the tissues or circulating in the blood called mast cells and basophils respectively. Further exposure to allergen then causes these cells to degranulate or burst, releasing a number of toxic inflammatory substances including histamine, leukotrienes and prostaglandins. Allergic reactions are characterised by their immediacy: that is, exposure to allergen causes mast cells and basophils to release their toxic inflammatory substances within seconds of exposure. This is why allergic reactions belong to the class of hypersensitivity reactions called “immediate hypersensitivity”. Histamine, prostaglandins and leukotrienes induce generalised eVects on the body, particularly lowering of the blood pressure which can lead to fainting, collapse and cardiac arrest, constriction of the bronchi or breathing tubes, causing shortness of breath and wheeze which may be particularly severe in asthmatics, and the swelling of the tissues, which may cause a rash on the skin but also swelling of critical organs such as the larynx which may block the airway and is another potential cause of death in severe allergic reactions. As allergists we recognise quite clearly which diseases are caused by, or made worse by allergic “hypersensitivity” reactions. These include asthma, allergic rhinitis (including hay fever), eczema, anaphylactic reactions to bee and wasp stings, reactions to latex proteins and some, but not all reactions to foodstuVs and drugs. In contrast the general public and many medical and allied health professionals, because they have had little training in allergy, tend to classify a much wider range of reactions to external agents as “allergic” inappropriately. This is typified by the situation with food allergy and intolerance. Food allergic reactions are immediate, reproducible and evolve with a very typical pattern in allergic individuals. It is possible to tell whether or not patients have true food allergy with a brief history and relevant simple tests. On the other hand, many patients (and often their doctors) attribute a range of non-specific symptoms to foods which occur much later after they have been eaten and very widely in their clinical manifestations. There is little or no evidence that such late reactions are caused by reactions to foods, and the term “allergy” is in this case not appropriate. If late reactions to foods do occur (and there is no definite evidence that they do except in rare patients with very well defined inborn areas of metabolism which cause biochemical abnormalities after eating certain foods, and with the exception of coeliac disease, a rare non-allergic hypersensitivity reaction to gluten found in various grains), their mechanisms are uncharacterised and consequently there are no suitable diagnostic tests. Allergic disease is characterised by the so-called “allergic march” in which infants predisposed to allergy typically developed severe eczema soon after birth. This is followed by manifestations of food allergies, typically to cow’s milk, egg, grains, nuts and fish which develop about the time these foods are introduced into the infant’s diet, and later allergic rhinitis and asthma. In such patients, allergic reactions to foods and airborne allergens such as pollens and animal danders can be demonstrated by simple tests such as skin prick tests. One of the major mysteries in allergy, however, is the fact that many of these diseases tend to remit clinically as the child gets older, yet this is not usually accompanied by produced production of allergic IgE antibodies. Having an allergic reaction is not, therefore, simply a question of whether or not the body makes IgE antibodies. Clearly, there are whole layers of understanding to be uncovered about what governs the presence and severity of clinical allergic reactions in patients and how this varies with time. It seems very likely that environmental factors, as well as possible genetic predisposition of certain individuals govern these processes, but little or nothing is known about their nature. Although there is unequivocal evidence that the prevalence of allergic diseases is rising with epidemic proportions, it is also very clear that the burden of disease is grossly underestimated for all types of allergy. There are several factors operating here. First, because allergy has only recently existed as a separate medical speciality in the UK, specific allergy training never has been, and still is not included in undergraduate and postgraduate medical training curricula, much of it goes unnoticed. For example, many patients with chronic allergic rhinitis are characterised as having a “permanent bad cold” and suVer needlessly for years on end when they could be helped by appropriate allergy diagnosis, identification of causal allergens, appropriate allergen avoidance advice and ancillary medical treatment. Many cases of acute “asthma” presenting to casualty 206 allergy: evidence
21 February 2007 departments are in fact acute anaphylactic reactions (a severe, generalised allergic reaction which may be fatal) caused by oedema of the larynx referred to above, and not asthma at all. Even experienced accident and emergency and general internal medical consultants have had little training in the recognition and subsequent management of allergic diseases. Food allergy reactions in infants often go unnoticed, since the symptoms of anaphylaxis are less dramatic (but still potentially lethal) in infants as compared with adults. Yet food allergy can cause untold suVering in children, with exacerbation of coexisting eczema, asthma and rhinitis. A further gap in recognising the burden of disease is that, because there is not NHS infrastructure for the management of allergic problems, many patients elect to treat themselves, often very unsatisfactorily, and never present to a medical practitioner. In many areas of the UK, there exist no allergy specialists to see these patients even if they do decide to seek help. A clear solution to all of these problems is to establish a network for allergy treatment across the UK, a course of action which was recommended recently by the House of Commons Health Committee but sadly ignored by the Department of Health. The socio-economic impact of allergic disease is tremendous and largely unrecognised. Untreated allergic rhinitis, for example, is in the top five causes of lack of sleep in the general population. It is also in the top five causes of loss of time from paid employment. Asthma rates slightly higher in the league table of causes of loss of days at work or school, with enormous socio-economic implications. For example, over 12.7 million working days are lost to asthma each year. Asthma costs the NHS an average of £889 million annually. One child in every year of every school in the UK now has peanut allergy, and in some children this is potentially fatal. Away from impressive statistics, bad hay fever in the summer ruins the social lives, morale and examination performance of millions of young adults every summer.
Treatment and Management Until recently no known treatment was proven to alter the natural history of allergic disease. There are recent exciting suggestions that certain forms of immunotherapy, particularly with modified allergens, may do so. While pharmacological and non-pharmacological therapies (not least sensible and authoritative allergen avoidance advice) have had a major impact on the burden of allergic symptoms, the key to cracking allergy is prevention. At present the level of research aimed at understanding the natural history of allergy, the role and scope of primary prevention and altering the natural history of the disease for the better is grossly inadequate. We have been lucky enough to set up, in collaboration with King’s and Imperial Colleges, Asthma UK (the country’s leading asthma charity) and the Medical Research Council the first MRC Centre for allergic mechanisms of asthma. Apart from this, allergy research is performed in isolated centres of excellence by a small handful of interested individuals. The lack of an organised and structured NHS allergy service has greatly hampered this process, resulting in few young doctor trainees who are interested in doing it, and lack of nationwide access to patients to participate in research projects. The most promising areas of research into preventing or treating allergy at present might be summarised as follows: (1) Strategies for prevention: attention to maternal and foetal nutrition, and other early interventions, such as allergen vaccination, which may alter the evolution of allergic disease. (2) Measuring and assessing life-time allergen load and exposure. (3) Drug allergy: organised clinical and epidemiological research, with assessment of outcomes of management by allergists. (4) Further development of allergen immunotherapy (the practise of exposing allergic individuals to progressively large quantities of the allergen at a distinct mucosal surface, such as by injection or under the tongue) is of proven therapeutic benefit. For example, patients with anaphylactic reactions caused by allergy to bee or wasp stings can now be cured of this problem with immunotherapy. With hayfever, immunotherapy can vastly reduce symptoms and transforms suVerers’ lives. There is also evidence that immunotherapy reduces the need for conventional medical therapy in asthma. Most interesting of all, however is the evidence that early immunotherapy may reduce the incidence of new allergic sensitisations and the emergence of clinical allergic disease in infants and children. Advances in the formulation and practice of immunotherapy are being made all the time. For example, sublingual immunotherapy for grass pollen allergy has recently become available in the UK. New modifications to allergens to increase their ability to turn oV the allergic immunological hypersensitivity response, through better understanding of the immune system and how responses to allergens are regulated, are emerging all the time. There is abundant scope for a nationwide allergy: evidence 207
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initiative to investigate the eYcacy and long-term eVects of these interventions. This is likely to save the health service millions of pounds in the medium to long term, not to mention the socio-economic impact of reduced loss of time at work and school. (5) Investigation of what factors determine an individual’s susceptibility to allergic disease. As mentioned above, this is not simply a question of whether or not they make allergic IgE antibodies to a particular allergen. Virtually nothing is known about this field, yet it promises such scope for understanding the role of heritable and environmental factors in turning clinical allergic reactions on and oV. (6) The impact of early intervention in food allergy, in terms of manipulation of maternal diet and the introduction of possible ancillary substances which will head oV the development of an allergic response. Despite increasing interest in the role of a foetal and maternal environment in governing the evolution of allergic disease in susceptible patients, few concrete recommendations have so far been possible, and this reflects lack of appropriate and directed research.
Government Policies To my knowledge, apart from the publication of pollen counts which are generally measured by private organisations, no government policy has directly addressed the epidemic of allergic disease or produced suYcient public information to aid suVerers with self treatment or by providing the impetus to seek specialist allergist advice. Housing policy and regulations pay little or no attention to allergy, even though the environment likely plays a major role in the epidemic rise in allergic disease. Factors such as nitrogen dioxide emissions from gas burners, the emission of volatile organic compounds from mass produced furniture and the growth of moulds and other allergens in damp or ill ventilated homes may all play a very important role in the epidemic of allergy. Simple design of homes to minimise the accumulation of allergens such as dust mites, or more research into eVective means of ventilation and control of humidity might revolutionise suVering from allergic disease. Food policy and labelling regulations have gone some way to help food allergy suVerers, but on the other hand, largely to protect themselves from legislation, many companies have overstated the likelihood of their products containing particular allergens (a typical example is the label that a food “may contain nuts”). Such practices are not helpful to the suVerer who may die from anaphylaxis from accidental nut exposure, and the situation may require expert dietetic input which is really only available at dedicated allergy centres.
Patient and Consumer Issues Even notwithstanding the impact of allergies on the quality of life of suVerers and their families, the figures, only a few of which I have quoted above, really speak for themselves. It is absolutely inconceivable to allergists how these issues are ignored when allergic disease is one of the leading causes of morbidity, suVering, NHS expenditure and socio-economic loss in the UK. It is widely perceived that this outrageous anomaly arises simply because allergic diseases are not political “hot potatoes” like cancer and heart disease. Certainly, government spending, health priorities and public education are certainly not the slightest bit attuned to the prevalence and impact of allergic disease. Finally, may I say a final word about “over the counter” allergy tests. Many so called “allergy” tests performed, for example, in health food stores or alternative medicine emporia are of no diagnostic value whatsoever. Furthermore, they are misleading in the sense that the patients are often given a completely erroneous and ad hoc list of foods or other substances they should apparently avoid, which not only does not treat the allergic disease but also leads to inappropriate dietary restriction, sometimes to the point of starvation, particularly in children with anxious parents. Even “over the counter” tests of accredited diagnostic worth, such as RAST (a blood test for allergic IgE antibodies), are eVectively useless unless interpreted in the light of the patient’s history, which can only be done by an experienced allergist. It is a constant source of dismay to allergists that practitioners oVering so called “allergy tests” of no diagnostic value are allowed to set up shop and dupe the public in such an outrageous manner, seemingly with no legislative control at all. The fact that these services are used so widely is on the other hand no doubt a reflection of the desperation of allergy suVerers in obtaining access to any form of help at all. In conclusion, allergy could eVectively be managed in the long term if the Department of Health was to allocate adequate resources and “kick start” the service across the country. This would lead not only to a structured system of management of patients with allergic diseases across the UK, but would also form an invaluable platform for research. 208 allergy: evidence
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At present, after rising from the ashes about six years ago, the speciality of allergy is once again struggling at the brink of death in the UK. Despite recognition of the speciality and a clear, full and exciting training programme, there are currently just eight young trainees in allergy across the entire UK. They are increasingly disillusioned about their future careers and see no growth of specialist centres where they can practise their art. The situation is something of a vicious circle since there are correspondingly few centres at which allergists can be fully trained. A career in allergy is exciting and oVers a real opportunity significantly to improve the lives of a vast range of people, young and old. It is imperative that the Department of Health facilitates a career pathway for these young people by undertaking the clear recommendations of The Royal College of Physicians and of the House of Commons Select Committee. I therefore implore the honourable members of the Committee to consider this dilemma gravely and beg them to take the appropriate action. 6 October 2006
Examination of Witnesses Witnesses: Professor Jonathan Brostoff, Professor Emeritus of Allergy and Environmental Health, King’s College London, Ms Kate Chatfield, Research Ethics Committee, Society of Homeopaths, Professor Chris Corrigan, Professor of Asthma, Allergy and Respiratory Science, School of Medicine, King’s College London, and Professor Edzard Ernst, Director, Complementary Medicine, Peninsula Medical School, Exeter, examined.
Q502 Chairman: Can I start by thanking you very Ms Chatfield: Yes. much for coming today to give evidence to our Committee? I am Lady Finlay. I chair this select committee of science and technology sub-committee Q505 Chairman: I wonder if I can start by asking all inquiring into allergy. Can I also welcome those who of you which techniques allied to complementary and have come to listen in to the session, who are seated alternative medicine are currently used in the UK for in the public gallery? There was an information note the diagnosis and the treatment of allergic diseases? Y produced and that has the declaration of interests of Professor Ernst: It is a di cult question because we all members of the Committee so we will not be are dealing with a flavour of the month type of restating those as we go through with our questions. therapy and they come and go quite frequently. A We have a lot of questions and I would therefore ask little while ago, we tried to assess this systematically you if you could please be precise and concise with by looking at seven leading lay books in your answers to enable other people to make a complementary medicine and for allergies we found comment and to make sure that we get through the 57 diVerent treatment modalities. It is big. questions. Can I ask each of you to introduce yourselves? Q506 Chairman: Would you be able to provide us Professor Ernst: My name is Professor Ernst. I with a list of those after the session? am professor of complementary medicine at the Professor Ernst: Not oVhand but if you give me a little Peninsula Medical School Universities of Exeter and time, yes. Plymouth. Professor Corrigan: I am Professor Chris Corrigan, a Professor Corrigan: The four commonest ones professor of asthma, allergy and respiratory science used for the treatment of asthma and allergy at King’s College, London School of Medicine, are acupuncture, herbalism or phytotherapy, Guy’s and St Thomas’s Hospitals. homeopathy and various physical techniques, spinal Ms Chatfield: I am Kate Chatfield. I am here to manipulation and the like. Some of these techniques represent the Society of Homeopaths and I am a claim to diagnose as well as treat allergy. For senior lecturer in homeopathy at the University of example, homeopaths and herbalists diagnose. Central Lancashire. Others take the diagnosis as read and work from Professor Brostoff: I am Jonathan BrostoV, professor there. There are lots of tests available on the of allergy and environmental health at King’s Internet, by post and in shops that are claimed to College, London. diagnose allergy including leukocytotoxic testing, electrodermal testing or Vega testing, kinesiology, pulse testing and various other miscellaneous ones Q503 Chairman: Ms Chatfield, could I just clarify including iridology. your professional background? Is that in nursing? Ms Chatfield: In homeopathy we have a very diVerent Ms Chatfield: No. I am trained as a homeopath. definition of diagnosis. It is not diagnosing a specific allergy according to a specific allergen. A Q504 Chairman: Specifically? homeopathic diagnosis for us literally means finding allergy: evidence 209
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst the right remedy for the person, so it is not a homeopathy could be of great benefit in eczema, conventional diagnosis in that sense. particularly with the kinds of patients that we get. We Professor Brostoff: Some of the so-called scientific have a very high percentage of children coming with tests for diagnosing allergy and in particular food eczema and related allergies.38 allergy that are marketed have dubious clinical Professor Ernst: There are virtually dozens of validity, even when put to double blind studies. That complementary therapies that have been submitted is one aspect, even if the techniques used in the to clinical trials. We have summarised them in a book laboratory are robust but the interpretation, I am which I have here and which I am happy to donate to afraid, is fallacious. In terms of the allergy patients the Committee. This material is systematically and that I see, many have used herbal treatments and I transparently summarised. I agree with my colleague. think we did the first double blind placebo controlled For no treatment modality is there good evidence trial of Chinese herbs in eczema in the early nineties that it is clinically eVective in asthma, atopic eczema which showed it to be remarkably successful, but we or hayfever. These are the three conditions that we were careful to exclude toxic elements in the herbs. As have included in our systematic review. the Chinese have been doing it for about 1,500 years, I think we might have a lot to learn from them! Q508 Chairman: I just wonder whether you might be able to comment on the term “holistic allergy Q507 Chairman: That is an example as to my second therapy”. Professor Corrigan, I also wondered what question which is whether there are certain types of you feel the evidence is for the role of physiotherapy complementary medicine that are more suited to in breathing techniques in patients with asthma. particular allergic diseases than others. You have Ms Chatfield: V I have no idea what holistic allergy cited one, Professor Brosto . I wonder if others therapy is. I have never heard of it. would like to comment? Professor Corrigan: There are various breathing Professor Corrigan: There is a vast body of literature techniques which can strengthen the respiratory that suggests that there is no net clinical benefit from muscles and these are of proven benefit in some many of these procedures, including acupuncture, patients with asthma and indeed chronic obstructive homeopathy and various physical techniques. Some airways disease. Anxiety plays a natural role in many physical techniques have been shown to improve the of the symptoms of asthma and teaching patients quality of life for some patients—for example, asthmatics—probably by teaching them how to to calm and control breathing, techniques allied breathe properly but there is no evidence that they to physiotherapy, have been shown to improve improve the disease. With herbalism you have to be asthmatics’ quality of life, presumably because they careful. We must not forget that many of the drugs help them to calm down and breathe more naturally. we use today have been derived from plants. It is There is no evidence these techniques improve the likely that there are still a few more to be discovered. severity or the natural history of the disease. The problem with herbalism as it is applied currently Professor Brostoff: Because allergy services in the UK is that the preparations are not standardised. The are minimal for the number of people who complain active ingredients are not known. The prescription of of allergy, patients will be forced to go and see people these substances is rather ad hoc and, because the who might use Vega machines or apply kinesiology. whole process is unregulated, there is the problem of Anecdotally, many of these patients improve. poisoning. There are well documented cases of toxins Whether that is placebo or due specifically to the such as organophosphorous pesticides in herbal technique, or it is a subgroup of patients who remedies and other toxic agents. Whilst there is scope respond, it would take very little to produce a clinical for looking at allergy treatments derived from study of suYcient power to show that the Vega or plants, this research should be organised more applied kinesiology in controlled conditions was systematically and the active ingredients should be eVective, either globally in groups of patients or in a isolated and their properties characterised. With the subgroup. I think it is very sad that eVort is not put one exception of herbalism, I do not believe there is into this but it is quite understandable. Private any good evidence that any other form of alternative practitioners are not going to pay for clinical studies. medicine produces a tangible benefit in asthma. 38 Out of a total of 11 randomised controlled trials investigating There are many studies and summaries of studies to the eYcacy of homeopathy in the treatment of seasonal allergic back this statement up. rhinitis, eight demonstrate a significant positive eVect. Results of a six-year study at Bristol Homeopathic Hospital, Ms Chatfield: In homeopathy, as far as I am aware, published 2005, show that over 70 per cent of patients with we do not have any significant evidence from chronic diseases reported positive health changes after randomised controlled trials for the treatment of homeopathic treatment. The most marked improvements were seen in children. 89 per cent of under 16 year olds with asthma asthma but we do for allergic rhinitis and hay fever reported improvement and 75 per cent felt “better” or “much and a lot of clinical of evidence suggests that better”, as did 68 per cent of eczema patients under 16. 210 allergy: evidence
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst
Q509 Lord Colwyn: May we assume that none of Q511 Lord Rea: Could we go back to Vega testing you has a problem with the eYcacy of the placebo and kinesiology which have been mentioned briefly? eVect? Could you remind the Committee exactly what these Professor Brostoff: I wish I could treat every patient techniques consist of and how are they used to with the placebo eVect. It would be much less diagnose allergic disease? contentious and have far fewer side eVects. Professor Corrigan: A Vega test or an electrodermal Professor Ernst: I have absolutely no problem with test is based on a couple of wires being connected to placebo eVects. In fact, as a clinician, I used to try to a small galvanometer or battery which generates a maximise them but I would like to point out that you small voltage. The machines look very impressive. do not need a placebo in order to generate a They have lots of knobs, switches and dials. They placebo eVect. impress the customers. There are various variations but the basic technique is that the subject holds one wire in one hand; the other wire is placed in various areas of the skin or other parts of the body which are Q510 Lord Taverne: Professor Ernst said that his deemed to be of diagnostic importance. Sometimes clinical testing of alternative remedies and treatments there is a plate in the circuit containing a vial of did not show any eVect. Could he comment on what allergen which looks very impressive to the customer. Professor BrostoV has said about the use of Chinese The only galvanometer readings that are generated herbs? by this process are caused by flow of electrical current Professor Ernst: This is very complex because across the skin and depend on how sweaty the patient Chineseherbsareawholeworldinthemselves. is or where exactly you put the electrodes. From these There are very few people who understand them and measurements, typically a list of substances is I am probably not one of them. They are usually produced and given to the subject and they are told given as individualised treatments so if you all have that they are allergic to these substances. These lists asthma and I am a Chinese herbalist I would take are entirely ad hoc and random. There is no evidence your pulse, look at your tongue and your that this technique can diagnose allergy. Applied constitution and so forth and give you all diVerent kinesiology is the science where practitioners claim to herbal mixtures, often containing a dozen or more be able to diagnose allergy from the tension in the herbal ingredients and plants. The potential for muscles of the outstretched arm. They will ask a interaction, for instance, is huge there. This patient to outstretch an arm and apparently, with approach has not been submitted to a clinical test. It years of training and experience, when the patient can be tested, this individualised approach, but it holds a vial typically of allergen in the other hand has not been. What my colleague spoke of was a they can detect changes in the weakness of the muscle standardised formula of certain herbs targeted for of the opposite arm and thereby diagnose whether or eczema in this case and there were indeed some not the patient is or is not allergic to the vial of positive results. Later on there were some negatives allergen that is being held in the opposite hand. This as well with that particular formula. That is a can be practised with surrogates. In other words, if diVerent way of dealing with herbalism. There is you have an uncooperative child, the kinesiologist the standardised herbalism where you buy a pill in can hold the adult’s hand and hold the adult’s hand Boots, or whatever, and there is the individualised again when they are holding the child’s hand. Again, herbalism. The individualised herbalism is the one they claim to be able to diagnose what that child is that has been practised in this country by all allergic to. This is all completely bizarre and, I am herbalists and it has not been submitted to clinical afraid, utter nonsense. There is no scientific evidence tests in relation to allergy. For some other or mechanistic base to suggest that these tests could conditions it has and the results have been negative. be remotely eVective. Professor Corrigan: There are herbs that have been shown to be eYcacious in isolated studies because they contain known, active, pharmacological Q512 Lord Rea: Is the diagnostic part of these medicines. For example, butterbur is a herb which techniques the same as treatment—as the therapeutic impairs the immune system and may treat asthma eVect—or once the diagnosis has been made is a very much along the same lines as conventional diVerent treatment applied? steroids. Coleus is another herb which contains Professor Corrigan: These diagnostic tests do not forskolin which is a bronchodilator. There are many necessarily proceed to treatment. Often, the patient is drugs in some herbs which may be eVective but what just presented with a list of substances to which they I deplore is the ad hoc use of these unpurified are putatively allergic and then they are just allowed medicines which may not be safe in an to walk away with it. They are not the basis for unsystematised and untried fashion. specific therapeutic regimens. allergy: evidence 211
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst
Ms Chatfield: They are then told to avoid those therapies, do you argue, compare with more substances. conventional treatments in eYcacy and cost? Professor Corrigan: Yes, typically they are and Ms Chatfield: As Professor Ernst was pointing out, typically they do to their detriment. with herbal practitioners there are diVerent ways of applying and prescribing herbal medicines, but it is Q513 Lord Broers: Presumably this leads to a the same with homeopathy. A homeopathic positive placebo eVect anyway, does it? The very fact prescription is based on the symptom picture that the that people have been treated with an elaborate patient presents with. The remedy is prescribed machine must— according to the symptoms that the patient presents Professor Corrigan: Of course. It is the fact that they with. With isopathy, the remedy is not individualised have been treated with an elaborate machine and that according to the symptoms but according to the they have often paid a large sum to do so which gives specific or primary allergen that has been identified. them the firm impression that the diagnosis must be For example, in the case of a birch allergy, it would right, which is appalling. be betula that was used as the remedy to treat that if it was an isopathic prescription. The remedies would still be highly diluted as they are with homeopathic Q514 Lord Rea: Have we any evidence at all about remedies. That is the diVerence between isopathy Y the e cacy of these techniques and could you give us and homeopathy. Generally speaking, I think an idea about how much a typical treatment would homeopaths would consider homeopathy more cost? eVective than isopathy but I do not think we have any Professor Ernst: Both these techniques have been evidence to show that. submitted to proper scientific tests. Some of these tests have been of high methodological quality. When they have, they have resulted in negative findings. In Q518 Lord Taverne: I was asking about the other words, there is no validity to either of these two comparison with conventional treatment. tests. I cannot comment on the costs. I believe it is Ms Chatfield: If you look at the outcome studies we around £50 per go. have, obviously they do not involve the placebo question but we have various high levels of Q515 Lord Rea: Would it be possible to suggest that improvement in large scale outcome studies all over the eYcacy is related to the skills and experience of the world with this kind of treatment. In terms of cost the practitioner rather than the complicated eVectiveness, we do not have enough information on techniques and equipment that they use? that either. What I would specifically like to see Professor Ernst: In these tests, obviously the would be research trials which compare the practitioners were experienced and, yes, there was no conventional treatment directly with homeopathic reproducibility, specificity et cetera, which you treatment in terms of eYcacy and cost. require from a diagnostic test to be valuable. Professor Corrigan: It is diYcult to define what an Q519 Lord Taverne: In a recent debate in the House experienced practitioner is in these cases. One can of Lords, the president of the Royal Society said that define an experienced practitioner of physiotherapy if medicines can really work even if only a single because there is a set training course but, with these molecule is left this would entail some fundamentally procedures, there is no standard training manual new scientific principle with amazingly broad written down. There are sets of instructions with ramifications and fundamental implications for the individual kits but it is diYcult to know experiment over the whole of science. Could you how somebody does become professional in these explain how the mechanism is supposed to work that techniques. achieves these astonishing results? Ms Chatfield: I think you know very well that I will Q516 Lord Rea: I was thinking, rather than skill or not be able to because we have not discovered that training, of the personality of the practitioner. yet. I am of the opinion—and I think a lot of Professor Corrigan: I suspect that has a very great homeopaths are who were initially sceptical when deal to do with it, yes, somebody who looks they came in and, for a number of reasons, are knowledgeable, authoritative and presents you with convinced by the evidence—that science is not a static a piece of paper in a solemn tone which you take as thing. It changes all the time and just because we do gospel. not have an explanation currently we do have a lot of people proposing diVerent theories about how it may Q517 Lord Taverne: My question is really addressed work. Just because we cannot explain it now does not to Ms Chatfield. What is the diVerence between mean it does not work. Yes, it will mean that science homeopathy and isopathy and how do these is revolutionised and I do not see that as a bad thing. 212 allergy: evidence
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst
Professor Ernst: There is a fundamental diVerence in Glasgow. The fact that you have lots of negatives saying we have not discovered the mechanism yet. 50 does not deny a positive. years ago, we did not know exactly how Aspirin Professor Corrigan: On a statistical basis, one would worked but we always knew that there would be a expect one trial in 10 to be positive purely at random. mechanism there because it is pharmacology. With Ms Chatfield: A major problem with meta analyses homeopathy, this is fundamentally diVerent. Science and homeopathy is that they incorporate lots of tells us that there is no mechanism by which it can diVerent kinds of prescribing and it would be work and that is an important diVerence. If we find prescribing for the whole person, prescribing for the the mechanism then we have to rewrite our textbooks disease, using isopathy, comparing them all, lumping of physics, pharmacology and chemistry. them all in together as if they are one thing when they Professor Brostoff: I do not think there is a problem are not. We do know that some of the older trials of with rewriting any textbook if new facts arise. The homeopathy were not robust in terms of the way that critical data is: has homeopathy in a sense been they were designed and carried out.40 shown in model systems in the laboratory. The answer is very likely to be yes, both in the Q521 Lord Colwyn: I am sure the panel would agree haematological system recently and also a long series that, despite the criticism, there is no doubt that these of experiments in Paris. I know there was controversy techniques—we can go back to kinesiology and Vega over those. The fact that the clinical trials in the testing and also homeopathy—have successes. I have homeopathic hospital in Scotland, David O’Reilley’s referred patients to a kinesiologist for 30 years and I studies, in three separate studies showed that these do not think he has ever got one wrong. were statistically significant in terms of active versus Professor Corrigan: I am afraid that is the sort of placebo suggests that whatever the mechanism is it anecdotal report we have to be very careful of. Such does bear thinking about. observations mean nothing outside a properly controlled trial. Anybody can convince themselves they have benefited, particularly the person who Q520 Lord Taverne: A Lancet paper recently recommended them, but I am afraid that does not compared 110 homeopathy trials with 110 constitute scientific evidence. conventional medicine trials and found there was no evidence whatsoever that homeopathy performed better than placebos. Q522 Lord Colwyn: It constitutes a grateful patient Ms Chatfield: The conclusions the authors came to usually. were based on eight trials of homeopathy, not 110. Professor Corrigan: We are all in the business of What they did was single out what they called the making patients happy. If that is all we are doing, high quality homeopathy trials and narrowed them maybe there is room for that but if we are talking down to eight trials of homeopathy, none of which about real science that is a diVerent matter. were reflective of homeopathy as it practised in the real world. These trials involved a combination Q523 Lord Broers: Professor Corrigan, would you of isopathy, and therapeutic prescribing, not agree that homeopathy at least does not suVer from individualised homeopathy. It was unbelievable that the dangers of herbalism in that if there are toxins they could draw that conclusion from eight trials that they are diluted beyond action? homeopaths would not even consider homeopathy.39 Professor Corrigan: Yes, absolutely. It is hard to see Professor Ernst: Unbelievable or not, the importance how they would be toxic but I do not agree that they of this Lancet paper that you quote lies not in that it are necessarily harmless because they may delay may be the only paper questioning the eYcacy of accurate, valid and pressing diagnosis. homeopathy. There are to my knowledge well over a dozen such systematic reviews published in the peer Q524 Baroness Platt of Writtle: There is some reviewed literature which all show the same thing, so concern that seeking help from complementary the importance lies in yet another confirmation of medical practitioners may delay the diagnosis of something that has been shown a dozen times before. allergic diseases by more evidence based therapies or Professor Brostoff: The fact that there may be a meta even lead to misdiagnosis, which could have analysis showing that many trials are negative does potentially fatal consequences. How would you not negate, for example, three positive trials that respond to this suggestion? David O’Reilley did in the homeopathic hospital in 40 It is misleading of Professor Ernst to quote results from 39 In the same paper the authors established that a far higher systematic reviews of homeopathy as if they are all negative. In percentage of homeopathy trials (21 per cent), than actual fact most systematic reviews and meta-analyses are conventional drug trials (8 per cent), were of highest quality. positive, and this includes comprehensive reviews and those This does beg the question as to how we are ever able to trust focussed on specific conditions including influenza, arthritis and the conclusions of conventional drug trials. allergic rhinitis. allergy: evidence 213
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst
Ms Chatfield: In homeopathy we do not pretend to a kind of evidence.41 I think the Chinese would be diagnose in the way that conventional medics do. horrified by what you have just said, that because Most of the patients that come to see us have already their medicine has not been scientifically proven it tried everything else. Then they try homeopathy. It is should not be used. a last resort kind of treatment for most people. We Professor Ernst: I agree with Professor Corrigan. It is also have a strict code of ethics and practice which a nonsense and it is very regrettable because it sets a our practitioners are bound by and within our code double standard for the first time in medicine of ethics and practice practitioners are told that they regulation and, for me as a researcher, it is should always point out to their patients the necessity particularly detrimental because it just puts any to visit a GP. We have never had a complaint of that impetus to do any further eYcacy research down to nature in the 29 years of the Society of Homeopaths the level of zero. We are freezing our knowledge of being in existence. potentially beneficial herbal treatments if we do not Professor Brostoff: The fact that allergy is taught at a ask for proof of eYcacy. remarkably low level in medical school, the fact that there are probably under five trainees in allergy for Q526 Baroness Platt of Writtle: Professor Ernst, you the whole of the United Kingdom and the fact that did say earlier that private practitioners clearly are several allergy clinics have now been shut means that not concerned with funding research into the eYcacy patients are not getting a fair crack of the whip in of what they do, but is there a need for real research standard allergy clinics. To take the questioners into eYcacy and are there any charities or other point, I have seen patients who have been to two or bodies that are funding research of this kind? three allergy clinics where a very important and Professor Ernst: Research funding is the most diYcult significant medical condition has been missed, thing in my life to obtain. It is nearly impossible and potentially fatal in one case, but the boot is it has become even more impossible over the last few sometimes on the other foot. If we train enough years because regulation of clinical trials is now allergists of a high quality, I do not think this such that it is very expensive, mostly geared up to question would be worth considering, but sadly we large pharmaceutical trials, and to conduct a trial do not. of homeopathy or herbal medicine under these circumstances would be very diYcult indeed. Public funds are by and large not available. The science Q525 Baroness Perry of Southwark: My question is select committee seven years ago recommended large about the standard of proof that the Medicines and funds to be made available. That has not happened. Healthcare Products Regulatory Agency uses. As Industry funds are non-existent so we are reliant on you will all well know, it registered its first herbal charitable funds which are very scarce indeed. medicine last November and, as I understand it, a herbal medicine gets onto the register only if its maker can prove that the substance has been used in Q527 Lord Colwyn: It has been about 10 years since traditional medicine for many years. They do not I visited you in Exeter. What is your level of research have to prove that it is eYcacious. Do you think this staV at the moment? Do you have a number of DHS is an appropriate standard of proof or should fellowships and PhDs there? complementary medicines have to prove their Professor Ernst: We have about 10 research staV in eYcacy to the same extent as more conventional Exeter which makes us by far the largest unit of that medicines? nature in Great Britain. We have no government Professor Corrigan: I am afraid this is appalling funding at all. We did not get any despite various nonsense. We have been campaigning as allergists to attempts. Basically, we live on charitable funds, the get allergen immunotherapy licensed by the MHRA most important of which is the Laing Foundation. for years. This is a very scientifically validated treatment which is of great benefit to thousands of V Q528 Chairman: How many prospective su erers with hay fever and still the MHRA turned comparative studies do you have under way at the us down because some patients have reactions to the moment? injections. It is very frustrating that they then Professor Ernst: Zero. It is not out of ambition; that is condone the use of these untried, uncharacterised my expertise and I cannot fund them any more so we and untested concoctions on the basis of no evidence have shifted our emphasis towards meta analysis of at all. It is completely impossible to understand clinical trials, not because we particularly think they and very frustrating for the practise of proper, are important. We think they are important but scientifically conducted allergy. 41 Although it is not in the form of randomised trials, surely well- Ms Chatfield: Of course, I do not think it should be documented use in real life cases over hundreds of years holds taken in isolation as a form of evidence but it is still some value. 214 allergy: evidence
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst clinical trials would be more important. It is simply not sure that this is entirely a good thing because, as I by default. pointed out, if you regulate traditional herbalists and there is no shred of positive evidence for their Q529 Chairman: I wonder if you could explain to us individualised approach, you regulate in my view the diVerence between immunotherapy and enzyme nonsense and that will result in nonsense. potentiated desensitisation and any dangers of Ms Chatfield: I would like to reiterate what Professor adverse reactions with either? Ernst has said. My understanding is that they are well Professor Brostoff: Classic immunotherapy as on the way to regulation. They are in the last stages. practised in the NHS and in the UK is incremental There have been many things that they have had to immunotherapy. That is, for the most part, it starts at sort out about who would be allowed to go on the a low dose and builds up. It is allergen specific based register in terms of the qualifications and kind of on skin testing and serology. Many studies are done practice they have, how they practise. They are on that. We did the first study of sublingual managing at the moment to sort all those out and immunotherapy which is a little more comfortable move on. for the patient and that has now been accepted by the European Academy of Allergy as a validated treatment for inhalant allergy—that is, hay fever and Q531 Lord Haskel: The Committee was quite sometimes asthma. There are other variations on this impressed with the regulation of the osteopaths and form of immunotherapy using titrated doses. EPD is chiropractors and also with the work that they did for enzyme potentiated desensitisation which contains continuing professional development. Is there any enzymes and a low level of allergen. This has been guidance for the general public to help them choose used for almost 40 years. It has had one study a reputable practitioner and how could this be published in the BMJ on hay fever which showed no improved? diVerence between active and placebo. I understand Ms Chatfield: Certainly I think regulation is the way there were significant problems with that study. to go and in homeopathy we would like to go for Anecdotally, the side eVects are minimal and statutory regulation ultimately ourselves. At the anecdotally many patients respond well to it. moment, we are in the process of voluntary regulation and putting together one register for all Q530 Lord Haskel: If we could move on to the the homeopathy professionals. For all of the forms of provision of complementary and alternative complementary medicine, we need some kind of medicines, some seven years ago this Committee professional body with clear guidelines, a code of produced a report and one of the proposals was that conduct, clear complaints procedures—all of these they should introduce statutory regulation for things we need in place. practitioners of herbal medicine and acupuncture. Professor Ernst: We have recently published a little The government decided to act on this in 2005. What piece of research where we have shown that progress has been made towards implementing these chiropractors, after having been regulated in the proposals? United Kingdom, have totally fallen asleep as to Professor Corrigan: I am afraid I cannot answer in a research. That proves the point that I have tried to professional sense but you only have to walk down make previously, that regulation is seen as a the high street to see that there is a great deal of substitute for evidence. Once we are regulated, we do deregulation still in existence. So far as I am aware, not need to show the world any more that what we any practitioner can put up a brass plate and sell are doing is any good. That seems to be happening on herbal medicines. Is that not the case? Certainly you a major scale and therefore I am happy for regulation can walk into any high street shop and have a Vega as it safeguards consumer issues and so forth but, if test. I do not see any regulation at all as a lay person it is used as a substitute for eYcacy or safety research and a consumer. I cannot answer you professionally it worries me. because I am not involved in the licensing of Professor Corrigan: Regulation does not mean the alternative practices. treatment is eVective. At best, it may protect some Professor Ernst: I am also not involved in these patients from being poisoned and it may protect regulatory issues but I know that chiropractors and some patients from charlatans. Once you do license osteopaths are regulated, as we all know, and them, they are under less obligation then to show acupuncturists and herbalists are well on the way to that what they do is of any benefit, which is being regulated as professionals. I believe there is an counterproductive. initiative to bring all the other complementary therapies under one regulatory umbrella. How far this has succeeded or advanced I am not aware of but Q532 Lord Haskel: Is there any useful guidance for I think a regulatory process is well on its way. I am the general public? allergy: evidence 215
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst
Professor Corrigan: Not that I know of. improved very significantly when specific foods were Ms Chatfield: It is not something I have seen, that eliminated, and of note these are patients where skin there is a decreased interest in research. That has not tests and blood tests are negative, so it is a completely been my observation at all. The decrease in research diVerent mechanism. I of course would put in a plea is due to the drying up of any funding. That is the for more interest in food intolerance. primary factor that aVects the level of research. Professor Corrigan: I agree with Professor Ernst. A lot Certainly within the professions there is still the drive of patients use complementary medicine more as an to carry out the kind of research that improves adjunct to existing therapy than anything else. A lot practice. It is not just about proving eYcacy but of it is peer pressure, pressure from the media: I have trialling diVerent techniques. tried this and it has worked for me for 10 years, these sorts of statements. Interestingly, if you look Q533 Lord Taverne: On the question of guidance, at studies, whereas many patients use these I know that opinion on the panel will be divided complementary therapies, a lot of them do not think V but would it not be useful guidance to issue a they are particularly e ective. It is almost a thing one health warning when so many people do resort to does these days, rather like getting a new car. I would alternative therapies? also endorse the principle that many patients in this Professor Brostoff: It might be interesting to issue a country do not have an allergist to consult and that is health warning about going into hospitals these days. a very important factor in people seeking help. One If you take malpractice, if you take 10 per cent of will seek help from anywhere if one is desperate hospital admissions being due to drug reactions plus enough. I think we can all understand that sort of MRSA, plus clostridium dificile, that would be more sentiment. That has played a role but largely I think appropriate at the moment and it is also a much it is also peer pressure and modern society that force larger problem. people to look at these medicines. Professor Ernst: From my perspective, guidance Ms Chatfield: What you call “peer pressure” I would against complementary, alternative therapies is call word of mouth and stories of successful nonsensical. Guidance against unproven or treatment. Certainly that is where most of our disproven treatments, yes. Many treatments in patients have come from when we have looked at the complementary medicine are unproven or disproven, motivation for coming. They have heard stories from but not all. Some have very good evidence, not in the other people who have been successfully treated. area of allergy, I am afraid. In these cases, guidance That is why they come. I cannot call that peer should favour the usage of these treatments. It is not pressure. When we are looking at particularly about a label, complementary versus mainstream; it children with allergies, their parents most often bring is about proof of eYcacy and safety. them because they do not want to use conventional treatment or, if they have used conventional V V treatment, they are worried about the side e ects and Q534 Viscount Simon: It seems that allergy su erers the long term usage of that. That is one of the main feel as if they are driven to try complementary motivators for parents who bring their children. medicines and therapies because the conventional treatments do not appear to be there. Is this right? Professor Ernst: I think all the evidence points to the Q535 Viscount Simon: Would I be right in thinking fact that it is used in addition, as a complement to, that if more allergy specialists were around the place rather than because it is not there and therefore we the demand for alternative medicines might reduce? Professor Corrigan: have to use the other type of medicine. The reasons In my view, dramatically, yes. why people seek it out are obviously complex. A level of understanding, empathy and even time which Q536 Viscount Simon: Professor BrostoV, is there a medicine at present does not aVord within the NHS role for complementary and alternative medicine in is, in my view, a very strong motivator for patients to severe brittle asthma? turn towards complementary practitioners. Professor Brostoff: What I am interested in, which is Professor Brostoff: There is a frustration with the food intolerance and aspects of nutrition, I would availability in the allergy field and the provision in the not call complementary medicine. I would call it National Health Service is so limited. My particular mainstream medicine and my brittle asthmatics all go interest is food intolerance. If patients do go to on diets. If I get one in three better, I think that is an conventional allergy clinics, the conventionally enormous yield. Keeping somebody out of hospital trained allergist is often not very interested or six times a year, to me, is not a little matter. involved in food intolerance. For brittle asthma, for example, John Ayres’s study in Birmingham was of Q537 Earl of Selborne: There are currently five NHS 60 patients put on an extremely rigid diet. He found homeopathic hospitals which oVer homeopathic that in about a third of the patients their asthma and other complementary treatments such as 216 allergy: evidence
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst acupuncture. Should we have more on the National Professor Corrigan: I would agree with that and if we Health Service and should the range of treatments are talking about cost eVectiveness do not forget that alongside conventional treatments be extended to it costs the NHS £100 million a year to treat asthma such therapies as Vega testing and kinesiology on the and allergy, not to mention the socio and economic National Health Service? losses from loss of time at work or school and poor Ms Chatfield: I do not really want to comment on performance in exams. The cost eVectiveness of an Vega testing and kinesiology. I think that is a eVective allergy service in this country would be separate issue but certainly with homeopathic overwhelmingly positive. hospitals we would welcome far more provision of Professor Brostoff: If you take general surgery or most homeopathy on the NHS because at the moment surgical operations, probably 90 per cent have not there is very little provision available and it remains been put to a true double blind clinical study and we the preserve of the people who can aVord to pay for are using empirical methods which sometimes work it in most instances. We would welcome any better than others. If homeopathy is satisfactory to opportunity to increase provision. the patient and adds something to their quality of life Professor Corrigan: I think it is sad that we consider and keeps them away from the NHS, I would support such an option when the conventional and it fully. professional allergy services that are available on the NHS currently are so few and so limited. It is possibly Q540 Viscount Simon: I would like to go back, if I a question of priorities, but that should be regarded may, to what Professor Corrigan was describing, the as a secondary issue. We are all in the business of equipment for Vega testing. If someone went along making people feel better. If people do feel better, and was Vega tested and the result was X, would the even if there is no tangible benefit, one might argue result be the same X if they went along to someone that that might be a suitable alternative to spending else half an hour later? more than two minutes with your GP discussing your Professor Corrigan: No. There have been well problems, or even your priest or your mentor. I could designed studies around this issue. This is one of the not condone expansion of homeopathic hospitals or few useless tests that has been conclusively proven any other alternative therapy to the detriment of useless by very well performed trials in which various setting up a well accessible, conventional allergy practitioners were asked to analyse the same patients V service within the NHS. and came up with answers which di ered no more from random. I think one can safely say that no is the answer. Q538 Lord Broers: I have a simple, technical question about homeopathy and drugs. Is it possible Q541 Chairman: I wonder if I could ask you all a to distinguish between homeopathic drugs after question in relation to research and research evidence they have been diluted? Is there any means of that we have heard often is not there and whether the distinguishing one from the other? outcome measures that are being used to assess these Ms Chatfield: Only by the label. diVerent modalities have possibly been the wrong outcome measures? How much have quality of life assessments been incorporated and how have the Q539 Lord Taverne: The question was about domains in those quality of life assessments been possibly expanding and financing more hospitals. Do evolved and validated? you think, as an alternative to this that, given the Professor Ernst: This is a question about any patient shortage of funds in the health service, the present centred outcome measure. In the past, medicine has expenditure on these five homeopathic hospitals is been accused of measuring what is measurable rather justified or can be justified? Ms Chatfield obviously than what is relevant. That has dramatically would say it is justified. changed. We have, if anything, too many quality of Ms Chatfield: Of course it is justified. I think you will life measurements rather than too few these days. V find when you look at the cost e ectiveness of Any good trial these days must include a measure homeopathy and what the provision costs, it is a very of quality of life both in mainstream and small proportion of the NHS budget. When you look in complementary medicine. In complementary at putting money into that kind of provision, you will medicine, it has largely been adopted so I do not ultimately save money in other areas. know of any reasonably good trial that totally Professor Ernst: I cannot think of a logical neglects the patient’s view in that sense. justification for treatments which are disproven or Ms Chatfield: I would agree with that in the main. unproven. In as much as these hospitals use proven Things have improved a great deal recently in respect treatments, they are justified. In as much as they do of how people are looking at the various outcome not, they are not justified. measures and how we can improve them and make allergy: evidence 217
21 February 2007 Professor Jonathan Brostoff, Ms Kate Chatfield, Professor Chris Corrigan and Professor Edzard Ernst them more suitable to the testing of the outcome that alternative medicine, amongst the population with we want to measure, of course. With the kind of the diVerent allergies. We know in the cancer field holistic treatment that we are measuring in about 50 per cent of patients who are undergoing homeopathy, we still do not have an outcome conventional cancer treatments are also using some measure that successfully can measure the eVect on form of complementary or alternative medicine. every level. By their very nature, randomised control Indeed some, such as reflexology and aromatherapy, trials are trying to measure very specifically. are provided within the NHS setting. I wonder if you Homeopathy is going to aVect the whole person. It is have any comments on that in relation to patients very diYcult to measure an outcome for a whole with asthma? person. Professor Corrigan: Yes I do. Interestingly, there is a recent paper by Slader and colleagues, three Q542 Chairman: I wonder if any of the work that Australian physicians, who address this very was done in the cancer field such as in Sequoia, which question: Complementary and alternative medicine is a very personalised quality of life measure, has been in asthma: who is using what? They estimate that 59 used in assessing any of these? per cent of adolescents and children are using Ms Chatfield: It would be if we had the money to complementary alternative medicines and somewhat carry out the trials. We would be looking at all of fewer adults, but less than 10 per cent of them make those things. it known to their general practitioners without Professor Corrigan: There are well designed quality of general or specific questioning. So probably life measures for asthma and rhinitis which are used thousands of people in the UK with asthma are in conventional, clinical trials but sadly not in trials using them. of homeopathy, for example. Professor Ernst: According to our own publication Ms Chatfield: They are. which we conducted with the National Asthma Professor Corrigan: I have just picked one at random Campaign in this country, and which dates back now from this year’s homeopathy where this doctor has about seven years, it is around a third of British treated 147 asthmatics and claimed that all but two of patients who use complementary therapies. I would them got better, based on his personal observation not want anybody however to over-estimate these and no objective measurements whatsoever. surveys because they are fraught with lots of Ms Chatfield: That is one paper. I would disagree diYculties. For instance, depending on how you there.42 define any of these umbrella terms like “complementary medicine” you can generate any Q543 Chairman: One of my questions relates to the prevalence figure. If I remind you that drinking tea is overall usage and if you have any figures on a herbal remedy, strictly speaking, then all of us use how many patients are using complementary and complementary medicines. Chairman: On that note, could I thank you for 42 Generally today researchers in any form of complementary coming. If there is additional information that you medicine have to strive harder to ensure validity and reliability would like to submit to us as a Committee, I would of their methods than their counterparts in conventional invite you to do so following this session and it will be medical research. It is more diYcult for them to get research ethical approval, to get funding and to get published. Extreme considered as part of the evidence that you have given bias can mean that their work is scrutinised to a high level. Even today. I would be grateful, Professor Corrigan, if we the authors of the Lancet meta-analysis that was so damning of could have a copy of the paper that you referred to in homeopathy concluded that the homeopathy trials were of better quality than the comparison trials of conventional the last couple of minutes. Thank you very much. medicine.
Supplementary memorandum by The Society of Homeopaths The Society of Homeopaths is the largest organisation regulating professional homeopaths in the UK, with over 1,300 Registered Members (RSHom). Homeopathy is a well-established Group 1 complementary and alternative medicine with a unique approach to illness. In common with other holistic therapies, homeopathic prescriptions are normally specific to the individual rather than the disease. The evidence for homeopathy in the treatment of allergies is extensive, from randomised controlled trials, large outcome studies and NHS practice-based services. The mode of action of homeopathic remedies in the body is not yet fully understood but there is growing evidence from bioassays that ultra-high dilutions have an eVect on living cells. 218 allergy: evidence
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Diagnosis
Homeopaths take a full case history and detailed symptom picture in order to find the remedy or remedies that most closely match the patient. They therefore “diagnose” an illness according to the homeopathic model. Patients increasingly choose homeopathic treatment for a range of mainly chronic conditions, including allergy, often because conventional medicines have not helped them. Homeopaths regularly treat people of all ages and many parents choose to consult homeopaths about their child’s allergies after consideration of possible side-eVects of conventional treatment.
Cost-benefit
The Smallwood Report acknowledged that homeopathic treatments oVer potential for substantial cost savings, particularly in drugs bills for primary care as well as fewer adverse eVects than conventional medicines plus a reduced need for follow-up appointments. GPs are able to refer NHS patients to registered homeopaths and most private health insurance companies and cash-plans consider homeopathic treatment a good investment. Consultation fees range between £30 and £100 and an episode of care may cost the NHS around £250 per patient. The Society of Homeopaths would welcome a full clinical assessment of the cost eVectiveness of CAM by NICE as well as an overall increase in research funding.
Integration
Homeopathy has long been available on the NHS through five NHS homeopathic hospitals. Registered Members of The Society of Homeopaths (RSHom) are largely engaged in private practice. 13 Society members oVer their services to SureStart (family medicine) and other members run well-integrated services within the NHS in Nottingham, London and Wiltshire. The Smallwood Report concluded that homeopathy could be relatively easily integrated into the NHS.
Regulation and Safety
The Society of Homeopaths is committed to the objective of a single register for homeopaths. As founding participants in the work of the Council for Organisations Registering Homeopaths (CORN), we believe that rigorous voluntary self-regulation will demonstrate to patients that the profession is fully accountable. The Society supports homeopaths in autonomous practice, working to high standards, within agreed bounds of competence, in any context where homeopathy is a useful intervention. Research has shown that whilst there may be under-reporting of adverse incidents due to the assumption that homeopathic medicines are harmless, the incidence of adverse eVects in controlled clinical trials was low.
Future Research
It is clear that many people of all ages are choosing homeopathy as their preferred option for treatment of allergy related conditions. Whilst an evidence-base for the treatment of allergies with homeopathy already, The Society of Homeopaths would welcome further pragmatic research in this area. Particular areas of investigation might include comparison with standard conventional treatment in terms of eYcacy, cost- eVectiveness, safety, patient preference and satisfaction.
References [not printed]
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Memorandum by Dr Jean Monro, Medical Director, Breakspear Hospital
Introduction I am the Medical Director of the Breakspear Hospital, which is a private day hospital that treats patients for allergy and environmental sensitivities, run by the Breakspear Medical Group. We have treated over 14,000 patients since 1982. The precepts of environmental medicine include detailed attention to sources of exposure to potential trigger substances, individual assessment of nutritional status, and the reduction of the total burden of physical, chemical and biological stressors, using specialised techniques. A holistic approach to treatment, the avoidance of drug therapy where possible, dietary amendment and supplementation, specialised elimination diet and challenge protocols, measurement and correction of environmentally triggered alterations in gut permeability and intestinal flora, use of proven methods of detoxification, measurement of specific biochemical pathways, and a low-dose desensitising technique are all integral to the approach adopted at the Breakspear Hospital. Your call for evidence requires answers on diVerent categories, as follows:
Defining the Problem (a) Allergy/sensitivity explained. An account can be found on our website: www.breakspearmedical.com. (b) Also annotated is an explanation of what is known as “the load phenomenon”. (c) The eVects of ongoing allergy/sensitivity damage are discussed. (d) The means of assessment by challenge, elimination and rotation diets. (e) The phenomena of bipolarity and addiction are addressed. In my opinion, the incidence of allergy is rising because of a concomitant exposure of individuals to environmental chemicals: indoor and outdoor pollutants, drugs, and food contaminants. These can all be part of a provoking total load, which aggravates encounters with natural agents. No consideration of this is normally undertaken by medical professionals.
Treatment and Management Food allergy: This is traditionally treated by avoidance. However, low-dose immunotherapy has been shown to be extremely eVective. Sublingual immunotherapy (SLIT) has an extensive reference base. Chemical sensitivity: An increasing number of people report adverse eVects from exposure to everyday amounts of common chemicals, for example perfume, paint, car exhaust fumes, which are tolerated by most people. The condition may develop after exposure to a large amount of a single chemical, or a low-level exposure to single or multiple agents. This is not acute toxicity, but is chemical sensitivity disorder. People aZicted often also develop adverse reactions to foods and inhaled particles. Biochemical individuality: Genomic variations result in diVerent responses to foods, drugs and other agents, and must be considered.
Treatments — Low-dose immunotherapy. — Nutritional support. — Detoxification. — Identification of possible infectious agents. These should all be pursued. 220 allergy: evidence
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Government Policies The Paris Appeal has now been signed by many international scientific key figures and by the Standing Committee of European Doctors, which represents all medical governing bodies and medical organisations in the 25 EU Member States.43 Amongst their nine principal recommendations are “the creation of a new medical specialty: environmental medicine”. Chapter 5 relates to Obesity, Cancers and Allergies. Item R41 is entitled Allergy management. This stresses “. . . recognition of allergology as a medical speciality in the framework of environmental medicine”. Section M163 states “Given the frequency and growing incidence of allergies, the complexity of etiological mechanisms, and the great number of diseases to treat specifically, the European Union and the Member States must contribute to acknowledging allergology as a fully-fledged medical specialty.”
Patient and Consumer Issues Patients attending the Breakspear Hospital have often expressed the benefits of treatment oVered to them here. We have undertaken market research surveys and an independent audit of patient satisfaction questionnaires, which have established the benefits.
Memorandum by the British Society for Ecological Medicine
1. Defining the Problem
1.1 What is allergy? What is the difference between allergy and intolerance? Allergy is an acquired sensitivity to environmental factors or foods, provoking adverse eVects. In the immediate past, the term has been limited to reactions whose mechanisms have been shown to depend on the “allergy” antibody IgE, and other sensitivities have been labeled intolerance. There is increasing dissatisfaction with this limitation because: — The original use of the term was much broader. — The so-called intolerances are heterogeneous and need diVerent managements since they include intolerances with an idiosyncratic biochemical basis as well as sensitivities which behave like allergies. — In clinical practice these allergy-like intolerances contribute to the aetiology of a wide variety of chronic illnesses including migraine, IBS, hyperactivity, asthma, eczema, arthritis, chronic fatigue, rhinitis, conjunctivitis, failure to thrive and other conditions which are “not medically explained”. — Many of these chronic conditions respond well to allergy management: symptoms are relieved, and subsequently prevented, when the provoking trigger(s) is identified and avoided (Addendum A). [not printed] IgE-mediated allergic reactions mainly include local reactions in and under the skin, of the airways, and of the gut and the severe general reaction, anaphylaxis. They are mainly provoked by pollens, moulds, animal antigens, house dust mites, insect venoms, a few foods and a few industrial chemicals. Non-IgE mediated reactions may also be provoked by these allergens but also by others including almost any food and a large number of chemicals: they may produce similar symptoms, but also chronic or recurrent symptoms involving virtually any body system.
1.2 What is and what is not known about the origins and progression of allergic disease? The increase in the prevalence of allergy over the last 50 years has been too rapid to be attributed to changes in the gene pool, and must be some sort of environmental eVect. However, the increase in the pollenoses (hayfever etc) has not correlated with an increase in airborne pollen, pointing to some non-specific eVect. Historically allergies started to increase after the start of the industrial revolution which occurred at diVerent times in diVerent countries. Within the UK, increases in pollenoses have correlated with increases in fine 43 Memorandum of the Paris Appeal—Environment and sustainable health; 9 November 2006, UNESCO, Paris. allergy: evidence 221
21 February 2007 particulate air pollution and with the increasing manufacture of and exposure to chemical pollutants. However the causal significance of this link has not been proven. Other evidence suggests that childhood infections may be protective.
1.3 Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such high prevalence of allergy? (a) The rate of increase in allergies is extremely worrying. If the link in 1.2 is correct, the continuing increase in the manufacture of and use of chemicals will be one factor, particularly in the UK which has a high population density and inadequate monitoring of fine particulate air pollution: pollution with relatively harmless larger particulates (PMios) has fallen but pollution with the much more harmful ultra-fine particulates has increased: these adsorb chemical pollutants and carry them into the blood stream. Increased release of synthetic chemicals within buildings from fabrics and DIY, and decreased indoor ventilation may also be a factor. (b) The UK has recorded inadequate levels of intake of several of the vitamins and minerals required for optimum function of the immune system: deficiencies in the foetus, infant and child may well contribute to the high rate of allergies. Disturbingly high levels of pollutants have been found in the human body, even in neonates: essential nutrients are required for the metabolism and excretion of chemical pollutants.
1.4 What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? (a) The first gap is the inadequate training of most GPs in allergy. The second gap is the thoroughly inadequate supply of allergists of any kind all over the UK so that most patients with allergies do not have a specialist diagnosis. The third is the fact that most non-IgE-mediated allergies are not recognized as such. (b) One of the main barriers lies in the poor training in allergies at both undergraduate and postgraduate level: resulting in many doctors wrongly thinking they know all they need to know about allergies and others being frightened of them, trying to have as little to do with them as possible. The other is the very poor recognition of the nature of non-IgE mediated allergies, even though they respond well to allergy management.
1.5 In addition to the impact on the health service, what is the overall socio-economic impact of allergic diseases (for example, absence from work and schools)? (a) Allergies used to be rare in childhood: everyone now knows a family with one or more allergic children, and the strain that this puts on them and on the schools. In contaminated neighbourhoods some schools keep a separate room for the pupils’ inhalers. (b) There have been marked increases in the prevalence of chronic illness in general in the last few decades and particularly of rhinitis, asthma, migraine, IBS and of “medically-unexplained symptoms”.
2. Treatment and Management
2.1 What is the effect of current treatments on the natural history of allergic disease? (a) Most patients with allergies are currently treated either with anti-allergy drugs, steroids and other anti-inflammatory drugs, or pain killers, or with specific drugs to moderate the symptoms (eg drugs for bronchospasm). Careful management of the drug regimes helps control the symptoms (for instance in asthma) but does not help (and may worsen) the natural history. (b) The natural history of allergies seems to be that some children grow out of their allergies naturally (although they may develop other allergies later in life), but this process is speeded up by avoidance: if trigger foods are avoided they may be tolerated after six months or a year. This may also happen in adults, where onset of allergies usually follows some form of insult and the trigger substance is 222 allergy: evidence
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often a favourite, and frequently-eaten food.” Continued exposure causing symptoms tends to worsen the allergic state and leads to sensitivity to additional foods or environmental pollutants. (c) Allergic patients tend to be deficient in several of the vitamins and minerals necessary for optimum function of the immune system: correcting such deficiencies seems to improve their general health and lessen their hyperactivity. Deficiencies in parents before conception and/or of the mother during pregnancy and lactation lead to poor development of the foetus/infant: the evidence suggests that this also aVects the immune system, and that it can be prevented by correcting the deficiencies before conception or during early pregnancy. (d) Specific desensitisation therapy is used in mainstream medicine to protect mainly against venomanaphylaxis: this method is risky and its use is therefore confined to specialist centres. (e) Low dose specific desensitisation therapy is used by non-mainstream allergists to protect against pollens, moulds etc and against food allergy of both kinds: these methods use extremely low doses of allergens and are virtually risk-free. These treatments allow most patients to tolerate moderate exposures to the specific trigger(s) covered and some patients, but not all, become less sensitive overall in time. These methods are supported both by randomized trials and by audit of groups of patients most of whom had had symptoms for many years before allergy treatment.
2.2 What is the evidence-base for pharmacological and non pharmacological management strategies? (a) For allergies, pharmacological management strategies are largely palliative, aiming to control the symptoms not the disease: the evidence-base for this is in standard medical practice. They are largely ineVective in combating the general fatigue and lethargy which accompany allergic reactions. (b) The so-called environmental approach aims to identify the triggers which provoke the symptoms, so that they can be avoided, or the patient protected (at least partially) using low dose desensitisation. The evidence-base for non-pharmacological management strategies is detailed in the book Environmental Medicine in Clinical Practice. Anthony HM et al. which can be obtained from the BSEM oYce. The evidence includes: — double blind studies of the management of food allergy in both children and adults with a wide variety of chronic illnesses from asthma to arthritis; — double blind studies of low dose desensitisation methods, mainly in rhinitis and food allergy; — long term follow-up audit studies of severely-aVected patients, half of whom had suVered previously for 10 years or more, and had been referred to a number of diVerent consultants (11 in one case) without relief; — published case studies; — the daily experience of doctors using these methods where it is not uncommon for patients to say that after all they had been through, they would not have believed that it was possible to feel so well.
2.3 Is the level of UK research into allergy and allergic disease adequate? No, it is not adequate. This is partly because of the individually-specific nature of allergies which does not readily fit into the standard randomized double blind format. Experiments can only be performed studying the allergens to which each patient is sensitive, and the symptoms provoked in each individual patient, and must be done during a window of opportunity unaVected by previous exposure. There is little or no publicly- funded research into non-IgE-mediated allergy, although there is considerable evidence that environmental management would reduce the burden of chronic ill-health with very large savings for the NHS.
2.4 What are the most promising areas of research into preventing or treating allergy? (a) More accurate figures for the prevalence of allergies could be obtained by a large study based in general practice if this was designed to identify all the patients with any of the chronic or recurrent conditions which have been reported to respond to any type of allergy management, with randomized matched subsamples of the patients referred for diagnosis and treatment to mainstream allergists or other consultants as appropriate, and to allergists using environmental methods. allergy: evidence 223
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(b) It would be possible to test the theory that correction of deficiencies of essential nutrients during pregnancy (or preferably before conception) would reduce the incidence of childhood allergy. A study could link investigation of key nutritional factors during pregnancy using objective tests, with the well-being of the infant on delivery and the occurrence of allergies and other conditions in childhood, in two groups in one of which deficiencies would be corrected and in the other, not. Ideally this could be controlled by groups randomly assigned to standard supplementation as currently recommended or to supplementation with a wider range of essential nutrients. (c) Cost benefit studies of environmental methods in several chronic illnesses, such as hyperactivity and serous otitis media in children, and irritable bowel syndrome, asthma, migraine and chronic fatigue syndrome in adults.
3. Government Policies
3.1 How effective have existing Government policy and advice been in addressing the rise in allergies? We welcome the slight expansion of consultant training of allergists, most of which is concerned with IgE— mediated allergy but this remains totally inadequate.
3.2 How is current knowledge about the causes and management of allergic disease shared within Government? As far as we are aware the DoH adheres to the general, circumscribed view of allergy. Some years ago MAAF funded a study of food intolerance which ignored important aspects of the natural history of the condition and resulted in useless and misleading results. It would be very helpful if the DoH were to fund appropriate studies large enough to establish the clinical value of management based on the wider conception of allergy. (a) Do housing policy and regulations governing the indoor environment pay enough attention to allergy? There has been co-operation on asthma and housing, but room for more. Encouraging the elimination of draughts helps save energy and improves heat retention but it also increases the retention of chemical pollutants which probably plays a part in increasing allergies. Government should be making more eVort to reduce the volatile organic compounds released from cleaning compounds and fabrics and encouraging the use of borax as a fire retardant.
3.3 How effectively are food policy and food labeling regulations responding to the rise in food allergies? Food labeling is improving but incentives should be given to manufacturers to establish separate production lines for peanuts so that peanut sensitive patients are not unnecessarily restricted.
4. Patient and Consumer Issues
4.1 What impact do allergies have on the quality of life of those experiencing allergic disease and their families? The eVect of allergies varies from minor to devastating. Severe peanut allergy and hyperactivity and asthma all dominate the lives of the families with suVerers and commonly lead to relationship breakdown. Many adults with severe allergy problems are unable to work, either because they are too ill or because they cannot find work in an environment they can tolerate. Their position is made worse by the fact that their condition is not widely understood and they are often treated as if their illness is imaginary, and denied benefits.
4.2 What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? (a) The first group to educate is the GPs. The pharmaceutical companies spend a lot of money teaching GPs (and other doctors) about drugs, often in lavish surroundings, or with trips abroad. There is no equivalent source of funding for allergy and environmental and nutritional methods of practice and doctors have to pay for their own tuition (which is arranged by this Society) except for the occasional lectures invited by postgraduate deans etc. Some GPs actually complain to the GMC when ecologically-minded doctors get their patients better when the GP had previously failed. 224 allergy: evidence
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(b) Although many suVerers are unaware of how they could be helped, there is currently less scope for educating the public, partly because they are in general ahead of the doctors and partly because there are so few allergists and ecologically-minded doctors at present that educating the public would be counter productive. (c) The most pressing need is to increase the numbers of allergists, and particularly ecologically-minded allergists (such as members of this society), throughout the country. Allergists have traditionally not been widely ecologically-minded, although this is changing. Most ecologically-minded doctors are practicing privately because there are no NHS jobs for them, except for a few who manage to combine this sort of practice with NHS general practice. Few of the private doctors in this field make a good living, and their finances are now being hit by the requirements of the Health Care Commission, and will be in the future by the GMC’s revalidation requirements. There is a serious risk that they will give up the struggle to practice in a way that they know is much more eVective than the standard pharmaco-therapy.
4.3 Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory? (a) No. Private doctors practising ecological medicine need to be relieved of some of the requirements which are appropriate for large organisations but not for one or two doctors oVering a much needed service. (b) An allergy service needs to be headed by a doctor with postgraduate training covering all aspects of allergy (such as that provided by this Society), although properly-trained nurses and dietitians can make valuable contributions. Currently doctors are much more highly regulated than complementary practitioners. When complementary therapy organisations were asked what they did, none of them claimed to practice allergy, but many of their practitioners are known to identify trigger substances and advise about diets etc which amounts to practicing allergy. It is unsatisfactory, and occasionally potentially risky for such people to practice like this without adequate training and without equipment to manage any possible emergency. (c) There is insuYcient testing and regulation of OTC tests. October 2006
Memorandum by The British Institute for Allergy & Environmental Therapy
1. Preamble The Institute is a professional association of some 300 holistic allergy therapists. Members are drawn from a broad spectrum of the healing professions, both mainstream and complementary ie doctors, pharmacists, nurses, mid-wives, homoeopaths, psychotherapists, osteopaths and others. The Institute was formed in 1987 in order to bring together therapists who were using the holistic techniques developed at the Ffynnonwen Natural Therapy Centre and Homoeopathic Pharmacy in mid-Wales. The information presented is based on the practical experience of working with allergy suVerers using the techniques developed and refined and taught over a period of nearly 30 years.
2. Definition The word allergy was originally coined in 1906 by von Pirquet, and was loosely defined as an abnormal reaction of the body. In modern terms this could be taken to mean “An abnormal response by the immune system—the body’s protective mechanisms—to the environment, where the body’s environment is defined as anything that can be touched, eaten, drunk, breathed or injected. Clearly this fits the holistic model as it encompasses all the activities of the immune system. Over the years, the scientific model has come to define allergy as a condition caused by an antigen/antibody response—which may or not be life-threatening. This is activity of the specific immune system, and as continuing exposure to the allergens increases the antibody load, the condition becomes progressively allergy: evidence 225
21 February 2007 dangerous. Although diVerent antibodies are involved, the physiology closely mimics the physiology of immunity against disease which has been closely studied since the days of Pasteur. By comparison, food and chemical intolerance and sensitivity have been accorded, in mainstream medicine, a role of minor importance. The symptoms occur as a result of either activity of the Non-specific immune system or a genetic lack of essential digestive enzymes. These conditions are generally not life-threatening, do not involve the antigen/antibody response and are more diYcult to diagnose as often a multiplicity of apparently unconnected symptoms are presented. All too often this has led in the past to diagnosis of hypochondria and unsuccessfully treated as such. Many factors may be involved in the high prevalence of allergic disease in the UK: — High levels of atmospheric pollution. — An increasing dependence on pre-packaged food as increasing costs or aspirations of families lead to more working mothers with less time or ability for fresh food preparation. — Use of plastics in food packaging leading to the pollution of foods by PCBs (Polychlorinated Biphenyls)—increasing the toxic load on the body and in particular the liver. — Increasing use of chemical preservatives and unnecessary colourings in foods. — Electromagnetic pollution of the environment—Power lines, Computer equipment, Mobile phones etc. — Increasing use of “recreational” drugs. — Increasing side-eVects and over-use of prescription drugs. — Overuse of oral antibiotics in the past causing imbalances in the natural flora of the bowel, increased levels of Candida albicans overgrowth and subsequent interference with normal digestive processes. — The sensitivity of many individuals to the toxic and electrical eVects of the over-use of dental amalgam as a restorative for damaged teeth, in spite of pressure from many dentists to use alternative materials. This material is still in use although reported evidence of its dangers has been widely reported in professional journals. — Unnatural changes in hormone levels caused by the contraceptive pill and HRT placing pressure upon the immune system, as do increased levels of stress often in the home, the workplace, finances, cost of living, school and other areas. These all have a deleterious eVect on the normal functioning of the immune system. — In the past, Food & Chemical Intolerance and Sensitivity have been consistently misdiagnosed, in many cases due to the refusal of the scientific and medical establishments to accept the facts of its existence. As awareness increases, correct diagnosis leads to a further apparent increase in cases and additionally, one would hope, to increasing acceptance of established methods of diagnosis and treatment. When Type 1 allergies (where the antigen/antibody response occurs) are identified, treatment is usually symptomatic and readily treated by the GP, using antihistamine, mast cell stabilising or steroid drugs. Food and chemical intolerances, although readily treatable by alternative means, present a considerable time and cost problem for mainstream medicine. Even when treated as above, the symptoms of Type 1 allergies are, in many cases, not totally relieved and so result in lowered productivity and absenteeism in both workers and children, as not only are allergic conditions exacerbated by stress, the conditions themselves are stressful.
3. Treatment and Management — Current treatments do nothing to reduce the incidence of allergic conditions. Treatment is concerned mainly with the relief of symptoms, rather than the prevention of development of the conditions. Prevention should be the main concern. — The current program of vaccination of infants and children is considered by many to be responsible for the development of allergic conditions in some children and research should identify ways of avoiding this. — If one considers the above, then one must also be very wary of the possible results of introducing an allergy vaccination program, bearing in mind that this, by its very nature would be directed at reducing only Type 1 allergies. 226 allergy: evidence
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— Research should be directed towards ways of reducing the allergenic potential of home, work and public environmental conditions. — Simple statistical evaluation of Alternative and Complementary methods already in use would perhaps be a starting point for the gradual introduction of these into mainstream medicine. — Already there are eVective Complementary methods for the identification and treatment of allergic conditions. These involve comprehensive case history taking, problem assessment, stress and lifestyle counselling, simple and inexpensive testing methods and low cost isopathic treatment. They involve consideration of the whole person, both psychological and physical. Incorporating these methods into GP surgeries by the training of Practice Nurses, would allow the eVectiveness of these methods to be assessed statistically and would also reduce GP workload considerably. A pilot scheme would cost little initially and then would be self-financing as expenditure on drugs would be considerably reduced. There would then be opportunities for the continuing development of already proven techniques.
4. Government Policies It is laudable that the Government has now begun to take notice of the position of allergy suVerers in Britain. It is regrettable that this attention has been so long in coming and that in the past the Medical establishment has ignored those of its members and also those complementary and alternative practitioners who have evaluated the problem and have worked to find solutions to it in the face of relentless opposition. — Food policy and labelling regulations are gradually responding to the demands of a general public that is very knowledgeable in matters of food allergy, and it should be recognised that the public have been educated in the main on the subject by the complementary practitioners of this Country. — Many people have, of necessity, been able to change their living environment in order to minimise their allergies and it is useful that regulations regarding building materials seem likely to be considered. It is hoped that soft furnishings—often a cause of inhalant allergies will also be studied. — In view of this, it is hoped that Government will understand that had it moved earlier the allergy problem would not have been as overwhelming as it now is. — There needs, however to be caution in order to avoid the spectre of over-regulation that could so easily, and indeed so often in the past, has overridden common sense.
5. Patient and Consumer Issues — The allergic condition has, like any chronic illness, a huge impact on the suVerer. Food intolerance and irritable bowel syndrome often dominate the thoughts, regulate the patients’ activities to a great extent and call for never ending vigilance. Hayfever is easily forgotten once the season has passed. Eczema creates a constant invariable routine of treatment and bathing. The list is endless. Nor should it be forgotten that the parent also will suVer for the child. — All information to be disseminated should be prepared from both the Medical and the Alternative points of view for it should not be forgotten that the many Complementary therapists in the Country have long experience of the consequences of the allergic condition. Perhaps the most underdiagnosed allergic condition in Britain is Coeliac Disease and Government could quickly correct this serious gap in its policy of preventative medicine by a simple inexpensive testing of children below secondary school age. — The British Institute for Allergy and Environmental Therapy is a self-regulating organisation. As a member of the British Complementary Medicine Association, both as a teaching establishment and an association, its Members are obliged to accept the strictest standards of practice and Code of Conduct. Admission to Membership is by its own Diploma Course and it is believed that all Complementary therapists should be Members of a well-regulated Professional Association for their own therapy with access to a central body of information. It is regretted that there are many unregulated centres oVering forms of allergy testing with no treatment or patient support. The sale of OTC allergy self-tests is to be deprecated as self-treatment, particularly in the field of food allergy can, without the advice of a qualified practitioner lead to dangerous under-nourishment. allergy: evidence 227
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Memorandum by Professor Simon Wessely, King’s College, London I am not an allergist, nor an immunologist. I am an epidemiologist, interested in the distribution and causation of illness, and a psychiatrist, interested in the social and psychological aspects of illness. I directed a unit at King’s College London that has studied many aspects of chronic fatigue syndrome and related unexplained illnesses such as “multiple chemical sensitivity” (MCS)44, and I now direct a unit that researches many aspects of military health, including Gulf War illnesses. I have published over 500 professional original publications on these subjects. We recently published a review of 37 “provocation” studies in which MCS suVerers were exposed to various stimulants in controlled conditions. The conclusions were that “persons with MCS do react to chemical challenges: however, these responses occur when they can discern diVerences between active and sham substances, suggesting that the mechanism of action is not specific to the chemical itself, and might be related to expectations and beliefs” (J Allergy Clin Immunol 2006: 118: 1257–1264). This supports the strong consensus amongst clinical and academic immunologists that the phenomenon of multiple chemical sensitivity cannot be explained by allergy and/or immunological mechanisms (in contrast for example to allergic reactions to single substances such as peanuts). On the other hand, there is convincing experimental evidence that this can be explained by psychological conditioning, in which exposure to a stimulus such as an unpleasant odour becomes associated with a physiological reaction. The fact that symptoms develop only when the person is consciously aware of the stimulus (as opposed to peanut allergy for example) and that in double blind controlled tests these reactions cannot be reliably reproduced, speaks strongly to a conditioning model. Social, cultural and psychological factors related to perceptions of risk further amplify these reactions. I am not saying, and do not believe, that these symptoms are imaginary or “all in the mind”, but I am saying that social and psychological factors have more explanatory power than immunological or allergic factors. Why does this matter? Considerable evidence shows that many (but not all) diagnoses of MCS are in reality misdiagnoses of other, often fairly straightforward, conditions such as depression or anxiety. A label of MCS not only means that such people then do not receive appropriate evidenced based successful treatments, but may instead receive treatments that do little good and in some cases considerable harm. I have in the last 20 years as a consultant seen a number of unwell patients who have received a diagnosis of MCS. So far this has only come from the private “alternative allergy” or “clinical ecology” sector. For some this has had unintended, but serious consequences for both health and bank balance. For me these have been some of the most distressing experiences of my clinical career.
44 “Multiple chemical sensitivity” has become a popular term, it would still be more appropriate to talk about chemical intolerance rather than sensitivity. MCS is not recognized in the WHO International Classification of Diseases.
Examination of Witnesses Witnesses: Dr Jean Monro, Medical Director, Breakspear Hospital; Dr Damien Downing, President, British Society for Ecological Medicine; Mr Don Harrison, Principal, British Institute for Allergy and Environmental Therapy; and Professor Simon Wessely, Psychological Medicine Division, King’s College London, examined.
Q544 Chairman: I would like to thank you for Professor Wessely: I am Professor Simon Wessely. I coming today. We have a lot of questions to get am Professor of Psychological Medicine in the through. I am sure that you may have comments Department of Psychiatry at the Institute of relating to the previous session and I wonder if you Psychiatry, King’s College, London. would please send those to us in writing after today’s Mr Harrison: I am Don Harrison. I am Principal of session. It may be that we have time at the end to hear the British Institute for Allergy and Environmental them but I think it would be more important for the Therapy. Committee to be able to question today and then your comments could be submitted afterwards, if you Dr Downing: I am Dr Damien Downing. I am would. I think you were here earlier on when I President of the British Society for Ecological said there has been an information note with Medicine and Editor of the journal Nutritional and the declaration of interests of members of the Environmental Medicine, and I am also a doctor. Committee. I am Baroness Finlay and I am chair of Dr Monro: I am Dr Jean Monro. I am the Medical this Select Committee inquiry. Could I ask you to Director of the Breakspear Hospital in Hertfordshire introduce yourselves and then we will go into the and also consultant to the Krankenhaus, North questions. Friedland in Germany. 228 allergy: evidence
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely
Q545 Chairman: Could I start by asking you all present at the surfaces of bodies, the whole of what is idiopathic environmental illness or multiple the outside surface and the surfaces of mucal chemical sensitivity? membranes. There the gatekeeper cells—I am going Dr Downing: Simply, multiple chemical sensitivity is to mention something because this is a scientific just another form of allergy that is getting worse and committee—the dendritic cells, are the gatekeepers of more common, as we see. There are reasons for that allergies. These are linked with some of the very fine which I can go into, but it is complex and one of the nerve cells which are linked to the autonomic nervous reasons which I think will in due course be proven is system called C-fibres. C-fibres transmit information environmental pollution and chemicals having a extremely fast and the information is passed into the disrupting eVect on the immune system and making autonomic nervous system and into the central all allergies worse. The obvious model for this is nervous system. There are two principal mechanisms rhinitis which is, paradoxically, worse in towns than in allergy. One is the local mechanism where in the countryside and tracks better with levels of reactions can occur peripherally and the second is environmental pollution and small particulates than central mechanisms where the neural system of with levels of pollen. I think that exactly the same allergy is invoked. We know that the neural system of thing is happening with that as with food intolerances allergy can be very easily switched on by exposure to and with chemical sensitivities. Ten years ago, the chemicals. There are receptor cites on these C-fibres Royal College of Physicians produced a report—it which will allow responses to be perceived quite may be 12 years ago, I am not sure—that said quickly. Hence there is in fact a physiological eVectively that all this stuV about food intolerances mechanism to explain a very swift onset of symptoms was a load of nonsense; and now your request for which can be perceived neurologically as well by submissions refers to the rise in food allergy as being individuals and often having an expression through a fact. I think that another 10 years will probably see the autonomic nervous system. the same sort of shift in our perception of chemical Professor Wessely: I am not an academic or clinical sensitivity. I certainly do not think that it is in any immunologist and I do not have postgraduate way idiopathic. Idiopathic is one of those words that qualifications in it, I am not sure that any of us do, doctors use when they are trying to pass the buck but those who do I do not believe would recognise really. that. The people in academic immunology and Mr Harrison: I agree with Dr Downing about the allergy in my institution and elsewhere repeatedly wording. Certainly I do not believe that multi- give the definition I have just given that this is where chemical sensitivity is idiopathic, which is of no symptoms arise which do not have a recognised known cause, but it does certainly appear to arise allergic, immunological or toxicological basis. If they from either a single substantial chemical exposure did, life would be easy and we would not be here. or quite minor long-term exposure to chemicals. Examples of that, just a few of them briefly: people Q546 Lord Taverne: Apart from excessive living in high pollution areas; factories; traYc; flight vaccination and these multiple chemicals, do paths; laboratory work; farming in particular, with members of the panel also think that part of cause of the spraying of pesticides and also operations in the allergy are electromagnetic fields, phone masts, animal husbandry such as dipping of sheep; excessive electric waves and these kinds of influences? inoculations in time of war, as the Gulf War Dr Downing: Personally no. I do not think that that Syndrome has shown; and perhaps surgical happens in the sense of people becoming allergic to anaesthetics because in times of stress, as in a surgical electricity, but I think it is likely that electromagnetic operation, the patient is introduced to a number of waves add to the overall pollution eVect that we are unusual chemical gases, things they are not used to, all experiencing. and that may be the basis for subsequent chemical Professor Wessely: On both of those things, first of all, allergies to appear. Certainly much of the problem Lord Taverne, I am not sure if you were actually with chemical sensitivity arises in a problem with agreeing with the idea that multiple immunisations is liver function and liver support is almost always a cause of these illnesses or not. required. Professor Wessely: It is an imprecise label. People Q547 Lord Taverne: No. develop multiple subjective symptoms in response to Professor Wessely: We did a lot of research on that perceived exposures for which there are no obvious throughout the Gulf War Illness and we showed that toxicological or immunological explanations. receiving multiple immunisations prior to the Gulf Dr Monro: I do not agree with that. I believe that War was associated with the development of there are explanations emerging now. There is a symptoms. In other words, it triggered it, but we were considerable amount of evidence that there are two not able to show that there was an allergic or principal pathways for allergies. Most allergies immunological basis to this association. We are now allergy: evidence 229
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely in the middle of a randomised trial to see precisely electrical equipment causing problems, there is in fact what was the explanation, so you have a link but we research which has shown that when people are put in are not convinced this was done to disturbances of a Faraday cage and exposed to diVerent frequencies the immune system. Likewise, on the mobile phones of very low levels they did respond with symptoms, we have published a double blind trial in the BMJ a and these were quite distinct symptoms such as few weeks ago where we allocated randomly people provocation of asthma. So although that was a small who were sensitive to mobile phones but they were piece of research it nevertheless does show that there then given sham or real stimulation, and they were are eVects which should be explored. With regard to not able to tell the diVerence, so again people report chemical sensitivity, yes, there is work but it is not sensitivity to the exposure but clearly whatever it being undertaken in this country, it is being is due to, it is not due to the influence of undertaken in the United States. Professor William electromagnetic radiation. Meggs has demonstrated that there are quite a lot Mr Harrison: On that subject, although in our of mechanisms which will explain some of the work we mostly concentrate on food, and chemical phenomena of chemical sensitivity. and airborne pollutant sensitivities and allergies, Professor Wessely: Academics always moan about it nevertheless we still look at the involvement of dental is hard to get research money and more should be amalgam in the mouth which also has an given but there is an enormous amount done on electromagnetic eVect and also during our case environment and health and I do not think it is that histories we always look at electrical possibilities diYcult to get money for research, if you have well- within the patient’s environment, either at work or in designed studies with good hypotheses and good the home. outcome measures. We have certainly managed to get research money in this area and so have many other Q548 Chairman: Given your mention of dental colleagues, so I do not think it is quite as diYcult as amalgam, have you done any work looking at that. I think it is hard to get money for bad research mercury and mercury leakage? and so it should be—but for well-designed studies Mr Harrison: No, I have not but in the past I have had there are mechanisms, and they do produce research prolonged discussions with the late J G Levenson, a grants which are carried out and published in dentist who was an expert in the field. reputable journals.
Q549 Earl of Selborne: Could the panel tell us of Q551 Earl of Selborne: Can you give us examples any projects currently underway to research the of organisations which provide funding? Are you mechanisms involved in environmental illness. funded by research councils? Perhaps you could also tell us whether you think Professor Wessely: All sorts. We get funding from the there should be further research into these issues and MRC, the Wellcome Foundation, we get funding who should carry it out? from the Department of Health, the Ministry of Dr Downing: I think to some extent we have had the Defence, from Leverhulme, from Joseph Rowntreee. answer to this question already in the previous There is a variety of research organisations. It is session. The current climate in terms of funding and obviously always easier in America because they just ethical clearance and regulation in general makes it have more money than we do and so there is more pretty much impossible in this country, and if going on there. That is certainly true and there are Professor Ernst with a team of 10 cannot manage to many centres looking at these issues directly across mount prospective clinical trials then our society with America, not just the one Dr Monro has mentioned a staV of half a person is hardly likely to do so. There but many others as well. may be other studies going on elsewhere; I could not speak on that. Q552 Lord Taverne: But are these research projects into environmental eVect ones which look at the Q550 Earl of Selborne: Could you or perhaps one of impact on allergies? the other members of the panel tell me who you think Professor Wessely: Yes there are. We have just should be funded to do this work? reviewed 70 such papers on provocation studies, so Dr Monro: Yes perhaps I could answer that. Dr Jaleil clearly someone has paid for those and they have Miyan at the University of Manchester has shown been published. I would go so far as to say we that the neural pathway of allergy exists in his probably do not need any more now. I think that is a biological tests that he has done. With regard to debate that is largely concluded. On mobile phones translating that to humans we would like to be able to and electrical hypersensitivity there is a huge amount do further research. We have done some preliminary of studies, particularly on the Continent where these work and we would like to be able to substantiate issues are much more debated. I do not believe we that further. With regard to the comment about need any studies on dental amalgam any more, for 230 allergy: evidence
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely example, there are hundreds of studies on that, and Q554 Chairman: Dr Downing, did you want to again it is a subject that is largely closed. make a comment briefly in response to that question? Dr Monro: That is not actually the opinion of Dr Downing: I do not personally do research these UNESCO. In the Paris Memorandum which was days, I am too busy editing the journal and other published in the November 2006 they said that they things, but where I would like to see research directed thought that environmental medicine should be would be at the eVects of environmental pollutants established as a specialty and, furthermore, that in general. allergology should be a sub- specialty of that, and they mentioned there particularly the eVects of Q555 Lord Colwyn: I just want to make a comment amalgams and mercury and they also emphasised the about dental amalgam as a dentist of longstanding. I eVects of pollutants, and they are calling for more have to say that amalgam probably would not get a research. Furthermore, the Standing Committee of product licence if it was produced today but if there European Doctors was signed up to by all 25 EU were a direction to remove amalgams, and there are governments and the agreements that they have millions and millions of amalgams, the NHS would produced in their memorandum are signed up to by go bust overnight. all of the professional bodies, representing doctors in Mr Harrison: It also would be unnecessary because V V each of the di erent 25 di erent countries, so in fact of course many people are not aVected by their they are all calling for more research. amalgams. Professor Wessely: I am a member of the European Chairman: I want to try and move on because we have Science Foundation’s Committee and several others got a lot of questions today so if you could roll your that consider this area and I know what we signed up answers up concisely please. for and I know what we called for. Of course we called for more research, absolutely, but I said on certain questions, such as the influence of dental Q556 Baroness Platt of Writtle: What is an amalgam on health, we have not called for more environmental allergist and how does a person research in that area. become one? Do these practitioners have to register with a regulatory body, and what qualifications must they hold? Mr Harrison: 30 years ago when I first started looking Q553 Earl of Selborne: I wonder if we could at allergic conditions, there were no regulations, establish where you are calling for more research. there were no therapists, or there did not seem to be Perhaps each member of the panel could tell us the very many. I began to pass on the results of my own last time they submitted a grant application and who work to alternative therapists and to health it was submitted to? practitioners too, and after about 10 years or so it Dr Monro: From our point of view, we submitted a became quite obvious that regulation was important grant application to the Lang Foundation and they because you collected a mixture of people in your have kindly said that they will sponsor that. That was seminars, some of whom wanted to work with submitted last year. patients and some who did not, so then we formed an Mr Harrison: The big problem with allergy, and I institute for the people who had attended seminars notice this did not emerge at the previous meeting, is and were practising allergy work in the same way and that allergy is a condition of great complexity. I have we achieved a measure of regulation that way. We mentioned various aspects of it and if you say our made sure that the membership were reasonably environment is everything we eat, everything we well-trained, that they had the interests of the patient touch, everything we breath, everything we smell, at heart, and that they were insured. Now we have both internal and external, then the complications reached the stage where the same standards apply, begin to arise immediately, so where is research to be and we also have continuing professional directed? When we work with patients, we look at development of course. We are ourselves regulated foods, we look at dust, pollens, moulds, we look at by the British Complementary Medicine Association the eVects of immunisation, the eVects of dental which I understand has a responsibility to amalgam, the eVects on the liver and the thyroid Government. We follow their precepts and we make gland. Working in this complex way, I believe is the sure that our members follow them too. That is the only way that we will reach satisfaction, so where one type of regulation that we have. We have a directs research is a very, very diYcult problem complaints procedure and I am happy to say that indeed because every patient is diVerent. There is not over all the years of the institute I think two a patient with an allergy; there are multiple patients complaints, or maybe three have been on the board, with multiple allergies, and it is very, very diYcult to all of which were dealt with satisfactorily as far as the direct both treatment and research. patients were concerned. allergy: evidence 231
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely
Dr Downing: The society which I represent, the Dr Downing: So I am an environmental allergist then! BSEM, is a society of doctors and you have to be a Fair enough. Somebody who comes to see a member doctor to be a full voting member. We conduct our of our society with these things would be approached own post-graduate training and we are yet again in on a much broader basis and we would be looking at discussions towards establishing that as a diploma or not simply the narrow definition of allergy that has similar. In order to become a member of the Register been used, which is kind of falling apart these days, of Ecological Physicians therefore you have to be a but is still there, which is that allergies cause IgE- doctor first and then to go through our training mediated diseases such as asthma, eczema and so course and to conduct an audit within your practice forth. We see a lot of people with a huge range of and to present case histories and sign a code of ethics. other diseases that have been shown in individual I am not sure that makes me an environmental instances to have allergic or hypersensitivity allergist—that is the problem I have with the mechanisms involved in them, and the link between question—but I hope that answers it as far as we are food intolerance and arthritis would be an obvious concerned. example of that. So somebody coming to one of our clinics would be assessed in those terms and would Q557 Chairman: So if I am hearing you right, you also have their nutritional status looked at, and they have a validated qualification which is awarded would have their toxicological status considered as by your body, is that correct, so you have an well, and of course we would also rope in lifestyle and assessment process? psychological factors. Dr Downing: We have an assessment process which is not yet validated but we are working towards that Q561 Baroness Perry of Southwark: I would like you with the Institute of Biology. to explain to us something about what I think is called the provocation or neutralisation test which is used by environmental allergists; how does it work? Q558 Chairman: And Professor Harrison, you were Dr Monro: It is a form of low-dose immunotherapy. talking about self-regulation. In your previous questioning you were asking the Mr Harrison: Admission to our institute for several panel on homeopathy and they said that the doses years now has been via our own diploma course. That used were very infinitesimal whereas in neutralisation is a course which is partly practical and partly techniques the doses are tested for an individual theoretical. Currently the course has been put up to according to the individual’s responses and it is a the University of Wales with a view to validation. It form of low-dose immunotherapy. It has been used as has been well received initially but as the mills of a sublingual form of immunotherapy and there universities drive exceedingly slow, unfortunately, it are now some 3,000-odd papers on sublingual is likely to be about another 18 months before it goes immunotherapy and how eVective it can be. I think forward to the committee. Dr BrostoV said that it was a technique that was approved by the European Academy of Allergy Q559 Lord Colwyn: Could it be said that the UK is and accepted by them. Furthermore, low-dose taking a leading role in environmental medicine? immunotherapy has been shown to be the most Dr Monro: We certainly have a society which will eVective disease-modifying form of treatment as represent doctors in this country, but I think that opposed to disease-suppressing form of treatment for there are quite a number of other countries in people with allergies. Europe which have got organisations which are promulgating interest in environmental medicine. In Q562 Baroness Perry of Southwark: As I understand the States there has been an established training it, the provocation test comes first and then is course for many, many years. Certainly in Germany followed by the neutralisation vaccines. Am I right? there are environmental medicine hospitals, which Perhaps you could tell me what quality controls there are paid for by the federal government, under the are for those vaccines that are used? auspices of various Krankenhaus and patients can Dr Monro: What is used is a series of diVerent attend there and their health insurance will pay for strengths of vaccines starting with one particular them. In Germany and in France and the States they strength and it is titrated as a low dose from there in have quite a number of organisations which will do strengths of perhaps one part in five, so the strengths this work also. of the initial vaccine are well known and they have been established. The dilutions are parts of that, Q560 Baroness Platt of Writtle: If a patient seeks perhaps one in 25 or one in 125 parts, just as an medical advice about a possible allergy what are the example, so that when one knows the original diVerences in approach between an environmental strength one can calculate what the strengths of the allergist and an NHS allergy specialist? others are. The point about it is that immunotherapy 232 allergy: evidence
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely has been shown to be beneficial. I can quote from a used—you identify the things that you suspect might paper from Nature Reviews Immunology in October be a problem and that is the item that is tested, and last year which says: “It will prevent the onset of new you might have three or four items in an individual or sensitisations to diVerent allergens, reduce the you might have ten. development of asthma in patients with allergic rhinitis caused by inhaled allergens, and it is disease Q568 Baroness Perry of Southwark: Since that New modifying rather than palliative. England Journal article in 1990, have there been any research reports showing that the 1990 report was Q563 Baroness Perry of Southwark: Where did you wrong, that these provocation tests do work, and can say that article appeared? you give us a quote? Dr Monro: That is from Nature Reviews Immunology, Dr Monro: Yes I can, I have got a dossier of them but, volume six, October 2006. in addition, as I say, since then there has also been a vast literature on sublingual immunotherapy, which Q564 Baroness Perry of Southwark: I was going to is part of the provocation testing technique, which ask about a double blind study of the provocation shows that low-dose immunotherapy is very eVective, tests, which I am still not quite clear about. You have and I am happy to provide the Committee with the talked a lot about the immunisation programme but relevant documents. I am not quite clear what the provocation test is. I Mr Harrison: I agree with the validity of the wanted to press you really on the study that was provocation test certainly but we use a diVerent type published in the New England Journal of Medicine in of testing. We use the type of testing beloved of 1990 where they said that the provocation test had no Professor Corrigan. We use muscle testing, we use value in identifying food sensitivities. Has there been kinesiology. The test is comparatively short and it any study afterwards specifically on the diagnostic can be anywhere between 20 and a couple of hundred test? allergens. The case history taking has to be long. The Dr Monro: Yes, there have been and I have a dossier remedies that are used and that are produced in our of information about it. That paper was by Jewett own pharmacy are dilutions of one in 100. In other and it was critiqued by a number of people who words, they are homeopathic centesimal dilutions actually practised provocation neutralisation. He did going up to the 30th centesimal potency; sometimes not actually practise it, he is an orthopaedic person, to the 200th and sometimes higher, but usually the but the point is that the critique has shown that the 30th is adequate, and so we are way beyond the level techniques that he was recommending were not of actual material in our remedies; we are looking at entirely valid. energy medicines rather than anything else. The test is short and more time is probably devoted to the Q565 Baroness Perry of Southwark: So the case history. provocation test is what, giving somebody a dose? Dr Monro: It is giving a dose of allergen which is at a Q569 Chairman: Again I am going to shorten you particular strength that I have mentioned and then because Professor Wessely has been patiently waiting that can provoke symptoms in a person which can be to make a comment. nullified by a weaker strength. Professor Wessely: The Jewett test in the New England Journal was one of a large number of double blind Q566 Baroness Perry of Southwark: So how many provocation studies and what these show is that provocation tests would you have to have before you where the blindness is maintained thoroughly, in could identify what it was that the patient was other words neither the patient nor the doctor is able allergic to? to guess or work out what the provocation is, they Dr Monro: Whatever the strength of solutions it is give consistently negative results, no better than that is being used, say wheat diluted to a fifth of chance alone. Where either the doctor or the patient a standard concentration, that can be used as is unblinded, they give positive tests. It is for that provocation. The next weaker dose could be used as reason that the provocation tests are not used to a treatment, so it is a series of diVerent strengths. diagnose sensitivities.
Q567 Baroness Perry of Southwark: How do you Q570 Baroness Perry of Southwark: I am grateful for find out which allergen the patient is reacting to? that. Could I just return to the diVerence between the Would they have to have 20 or 30 diVerent allergens neutralisation process that Dr Monro is talking given to them as provocation? about and conventional sublingual therapy which we Dr Monro: They may have to but quite often if one have certainly seen practised for example in Germany has a history of a problem in an individual—and that and elsewhere. What is the diVerence between the is where the skill of the environmental physician is two? allergy: evidence 233
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely
Dr Monro: The diVerence is simply that one uses in a Dr Downing: You are talking about an intervention neutralising technique a series of diVerent solutions trial if you say a control trial. There have been studies and one uses the solution which produces no adverse that have shown—and I have a number here—that eVects as a treatment, the strength can then be allergics in general are short on a variety of nutrients increased. It is perfectly safe to do sublingually of which you are quite right zinc leads the league with because there are known to be very few what are vitamin C and the B vitamins and so forth. called mast cells in the mouth and under the tongue Lord Colwyn: My apologies for having to cut it so so that a person can be given a treatment very safely short. without the likelihood of adverse eVects. So the neutralisation technique is to find a strength which Q576 Lord Rea: Again asking a question that could gives no symptoms and then you can increase the occupy an hour, is there a possibility that some dose thereafter sublingually in a form of low-dose allergy treatments simply have a placebo eVect rather immunotherapy. than decreasing their true allergic response? Mr Harrison: Yes, I think so. I do not think that Q571 Baroness Perry of Southwark: So it is diVerent is anything new. I think that we must marshal from the sublingual therapy which is used in all the aspects of treatment, both physical and conventional allergy treatment? psychological, in the treatment of a patient as a whole Dr Monro: It is not entirely diVerent. As I say, one can because, as I said, the allergy problem is a very use one of the strengths and then build it up so that complex problem and many, many patients come to in fact it becomes the same thing. us having run the gamut of the NHS, regretfully unsuccessfully, because all aspects of their problem Q572 Chairman: Could I just clarify, would that are not addressed. Lifestyle must be looked at; the technique apply to something like peanut allergy? comfort of the patient must be looked at; the Dr Monro: Yes it has been used for peanut allergy but psychology of relationships must be looked at; and it is not commonly used and there have been only two anything that reduces the stress. The allergy picture reports of sublingual immunotherapy causing any on test reduces as the stress level reduces, so if we can major eVect, and that was when it was done in a rush get the patient to reduce their stress level, if we can desensitisation for peanut allergy. give them a belief in a positive outcome, then that reinforces the physical aspects of the treatment, so we Q573 Lord Colwyn: This is a question for Dr must bring all these things together. Downing. In your evidence you said that allergic Professor Wessely: Yes, obviously the placebo eVect patients tend to be deficient in several of the vitamins occurs across medicine and all of us would be a lot and minerals necessary for optimum function of the poorer if it did not. There is also the nocebic eVect as immune system; correcting such deficiencies seems to well, I am afraid, which is where the placebo eVect improve their general health and lessen their hyper- makes you worse. For example false allergy testing reactivity.” I would agree with that statement, can make you worse by reinforcing the belief that you namely that possibly zinc and vitamin C are some of have an illness that in fact you do not and that there the major oVenders. Can you give us an answer on is a relationship between things when there is not, and what is the evidence for this statement—and you are by drawing attention away from the real cause of going to have to do it in about 60 seconds! illnesses, so it is not just a straight situation. There is Dr Downing: It is a good job that I prepared a written also a lot of literature on the nocebic eVects of some response which gives a number of things. The short interventions and tests, all of it highly relevant to answer is, yes, there is quite a bit of evidence but that this subject. environmental allergies, as we are now calling them, are no diVerent from the rest of allergy in that respect, 45 Q577 Lord Haskel: You have told us about the it is true of all asthmatics and allergics. regulation of practitioners. What about the clinics Lord Colwyn: Are you aware of any control trials that and the allergy treatments which are provided; are have been undertaken which have been published these adequately regulated and what could the and peer-reviewed? Government do to protect the public from ineVective Dr Downing: On treatment? allergy treatments oVered in these clinics? Mr Harrison: I can only speak about the treatments Q574 Lord Colwyn: Yes. that our members oVer. The remedies that they Dr Downing: Somewhat more limited. receive are made in a homeopathic way. They are remedies which have been tried and tested and Q575 Lord Colwyn: To support your claim about produced for our members, something like 20,000 vitamins and minerals? remedies a year, and these are going to patients who 45 Please see supplementary evidence. are either self-referred or referred by friends or, 234 allergy: evidence
21 February 2007 Dr Jean Monro, Dr Damien Downing, Mr Don Harrison and Professor Simon Wessely more importantly, referred by GPs. As far as the Dr Monro: I was just going to say with regard to Government is concerned, it is already regulating doctors, we have the Health Care Commission, we the preparation of homeopathic medicines. The also have GMC validation, and also we have to do distribution of them should not be open to the CPD accreditation with them. Yesterday, or perhaps normal aspects of commerce because, for instance, today, there is a new five-year appraisal for doctors putting allergy neutralisation remedies on the shop that is being instituted. With regard to the products shelf would be entirely irresponsible—no doubt that we use the neutralising vaccines or the low-dose very attractive as a money-making proposition but immunotherapy vaccines the Medicines and Health totally irresponsible—because people would just go Care Products Regulatory Agency is involved in and help themselves, dip into them, take this or supervising those so there are all the regulations as that and waste their time and money. How the far as doctors are concerned, and indeed the care Government would regulate homoeopathically standards people are getting a more standardised prepared medicines further, I am afraid that is format for their rules of interpretation now. beyond me, I do not think they could manage it. Q581 Chairman: I think we need to finish here. I just Dr Downing: If you are talking about doctors running think it would be very helpful if in one short phrase clinics of this sort, then it is hard to see how we could you could each tell us how your private clinic services be more regulated, quite honestly. communicate with the patient’s GP what has been happening? Q578 Lord Haskel: It is the clinics and the treatment Dr Downing: We send a letter direct to the GP and any clinics which they provide that we are concerned other doctors after first consultation and after any one of which there is a significant event and after about. other ones. The patient has a health dossier and there Dr Downing: Yes, a clinic run by a doctor of that sort will be a summary of the consultation. would come under the terms of the Health Care Dr Monro: The same pertains in our facility. Patients’ Commission and therefore also the National doctors always receive letters. Patients are allowed to Minimum Standards. A number of us have either say whether or not they want their doctor to receive gone through the process or are going through the information and the responsibility then rests with the process at present, and I am myself, and I have to say doctor in the facility as to how they handle that. Our that it has been challenging but I think it has been practice is always to give a report to the patient to valuable and enabled us to improve what we do and hand on to their doctor if they should decline to have the service that we provide. a direct communication. Mr Harrison: Where patients are referred by their doctor, then automatically the doctor receives an Q579 Lord Broers: But are you required to do that? assessment of the patient’s condition, the treatment Dr Downing : Yes. administered, and the subsequent treatment recommended. Many patients who are self-referred Q580 Lord Broers: To register with the Health Care do not wish communications to go to their doctors. Commission. Nevertheless, one does sometimes, unfortunately, Dr Downing: Yes. find other conditions that are present and then the Mr Harrison: We ourselves are not. Our members patient is asked for permission to refer to the doctor, and then of course the doctor gets an explanation of have to rely on the regulation that comes from the what has been found and how and why and one hopes association as a whole. We have to rely on ourselves then that the patient will go back to them. to put the regulations in place. I have been a qualified pharmaceutical chemist for 50 years and I am headed Q582 Chairman: Professor Wessely? by the Pharmaceutical Society, I cannot put a step Professor Wessely: I do not do private practice. out of place, and I have to ensure that our members Chairman: Fine, could I thank you for coming today. toe the line, and I am pleased to say that they do. If there is additional information that you would like They would be removed from our register to give us as a Committee please do write in and it will immediately if they cause problems. We are open to be considered as part of your evidence. It will be listen to patients who have been to therapists who are helpful if the references that you have referred to members of our association so the patient has a direct could be sent in to the oYce, in particular the paper line with which they can communicate and get that you prepared for us today, Dr Downing; that answers. would be most helpful. Thank you very much indeed. allergy: evidence 235
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Supplementary memorandum by Dr Damien Downing, President, British Society for Ecological Medicine In written evidence, the BSEM said that “allergic patients tend to be deficient in several of the vitamins and minerals necessary for optimum function of the immune system: correcting such deficiencies seems to improve their general health and lessen their hyper-reactivity”. What is the evidence for this statement?
Evidence for Vitamin Deficiencies in Environmentally-Sensitive Patients Ross G H, Rea M D, Johnson A R, Maynard B J and Carlisle L. Clinical Ecology VI(2) (1989) Serum Zinc in a Series of Allergy Patients Maberley D J and Anthony H M. J Nutr Env Med 7(1):62–3 (1997) Bronchial reactivity and dietary antioxidants Soutar A, Seaton A and Brown K. Thorax 52(2):166–70 (1997) Dietary fats and asthma in teenagers: analyses of the first Nutrition and Health Survey in Taiwan (NAHSIT) Huang S L and Pan W H. Clin Exp Allergy 31(12):1875–80 (2001) Vitamin A status in children with asthma Arora P, Kumar V and Batra S. Pediatr Allergy Immunol 13(3):223–6 (2002) Serum vitamin levels and the risk of asthma in children Harik-Khan R I, Muller D C and Wise R A. Am J Epidemiol 159(4):351–7 (2004) Levels of coenzyme Q10 in asthmatics Gazdik F, Gvozdjakova A, Horvathova M, Weissova S, Kucharska J, Pijak M R, and Gazdikova K. Bratisl Lek Listy 103(10):353–6 (2002) The role of selenium, zinc and antioxidant vitamin supplementation in the treatment of bronchial asthma: adjuvant therapy or not? Riccioni G and D’Orazio N. Expert Opin Investig Drugs 14(9):1145–55 (2005) Dietary intake in patients with asthma: a case control study de Luis D A, Armentia A, Aller R, Asensio A, Sedano E, Izaola O and Cuellar L. Nutrition 21(3):320–4 (2005) The influence of the dietary intake of fatty acids and antioxidants on hay fever in adults Nagel G, Nieters A, Becker N and Linseisen J. Allergy 58(12):1277–84 (2003)
Supplementary memorandum by Mr Don Harrison, Principal, British Institute for Allergy and Environmental Therapy I am grateful for the opportunity to oVer additional material to the Committee as a number of the questions that I was not asked to answer at the meeting are within my sphere of interest and knowledge. I am a member of the Royal Pharmaceutical Society of Great Britain, having a degree in pharmacy; a graduate Member of the British Psychological Society, with an honours degree in psychology. I have worked in community pharmacy, holistic medicine and homoeopathic pharmacy since 1954. I trained extensively in physical therapy, psychotherapy, kinesiology, use of the Vegadevice, Bowen therapy and NLP, and have worked for the past 30 years as an holistic allergy therapist and homeopathic pharmacist, during which time developing holistic techniques for allergy identification and treatment. As Founder and 236 allergy: evidence
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Principal of the British Institute for Allergy and Environmental Therapy, I believe that if I briefly describe the work of the Institute this will answer, in context, many of the questions that were raised by the Committee in relation to alternative and complementary therapy. During the development of the techniques used by members of the Institute in the identification and treatment of allergic conditions, a number of testing techniques were evaluated. These included the tests commonly used in NHS allergy clinics as well as the Vega test and Applied Kinesiology (Muscle testing). It was found that, of these, Applied Kinesiology was the most simple, inexpensive, comfortable and accurate test in the hands of a trained practitioner, and the most easily understood by the patient, including children. Treatments were developed along homoeopathic/isopathic lines, and these treatments are matched with the results obtained from the testing procedure. The remedies used are prepared using the techniques of homoeopathic pharmacy, the starting point being a sample of the oVending allergen in each case, usually prepared and succussed to a dilution of 100-30. The diVerence between a homoeopathic and an isopathic remedy is not one of substance but one of prescribing. Homoeopathic medicines are prescribed following an examination of the symptoms presented by the patient, and an attempt is made to match those symptoms to the “symptom picture” of the remedy according to the Materia Medica whereas Isopathic remedies are prescribed by identifying the causative agent and matching the remedy to this as an oral immunization. Following the initial treatment, a re-test and consideration of changes in symptomatology indicates the progress of treatment and following the re-test further treatment is given if required, dealing with the oVending allergens in a logical progression, the aim being to normalise the patient’s response to potential allergens. Because allergies are caused by a number of diVerent physiological reactions, and are exacerbated by stress, by dietary insuYciencies of vitamins and minerals and genetic absence of certain enzymes, attention is also paid to correct functioning of glandular systems, the eVect of mercury amalgam, residual bacteria, viruses, yeasts and other parasites and a number of other factors. The patient is encouraged to make beneficial lifestyle changes if necessary in order to reduce both physical and emotional stress. The Institute is a group of some 300 like-minded therapists drawn from the medical, nursing, pharmaceutical, osteopathic, chiropractic, homoeopathic, herbal, nutrition and other health professions, many dedicated to allergy work, but some who practice allergy work in addition to their original orientation. As an estimate, at least 2,000 patients are treated annually. Admission to the Institute membership is by Diploma Course and examination. The members are regulated by a code of ethics based on that of the British Complementary Medicine Association, and all carry professional liability insurance. There is a complaints procedure available to patients, who have easy access to the Institute if needed. The Institute has been in existence since 1987 and has dealt with only three complaints in that time, all minor and all satisfactorily resolved. Patients are mainly drawn from those whose mainstream treatment has been less than satisfactory, are either self referred, or referred by their GP. A system of Continuing Professional Development is in place. It is believed that the cost of treatment as outlined is aVordable by most patients and that the total cost, which may be funded by health insurance, is usually of the order of £100 to £150 and represents a fraction of the cost of allergy treatment as undertaken by the NHS. 12 March 2007 allergy: evidence 237
WEDNESDAY 28 FEBRUARY 2007
Present Colwyn, L Platt of Writtle, B Finlay of Landaff, B Rea, L (Chairman) Selborne, E Haskel, L Taverne, L
Memorandum by the British Association of Dermatologists
Inquiry into Allergy with Reference to Skin Disease:Call For Evidence
1. Defining the problem: Several skin diseases have an allergic basis or an allergy-associated component. The most common can be summarised as follows: Allergy in eczema: (a) Diagnosis: in a patient with eczema (dermatitis), it is often diYcult to distinguish contact dermatitis (allergic or irritant) from other types of eczema. In fact, pure contact dermatitis is uncommon— almost always constitutional and other factors are involved. This is one reason why people with skin disease are best assessed by a dermatologist as the specialist with a full education in the diagnosis and management of skin diseases. (b) Patient pathway: A Department of Dermatology normally should be the first point of referral for patients with eczema, for the reasons mentioned above. It can be diYcult to diVerentiate atopic eczema from contact dermatitis—indeed the two not uncommonly co-exist. Departments of Dermatology provide a holistic approach to the management of the eczemas including allergic aspects related to the skin, often using clinics led by specialist nurses. Latex allergy: All dermatologists who deal with contact dermatitis are competent to manage latex allergy and will be called on to do so regularly. In many hospitals the dermatologist is the first port of call for latex allergy. Several dermatologists have written the latex policy for their hospital, with collaboration from other specialities including allergists and immunologists. Urticaria and angioedema: All dermatologists are trained to manage these conditions and, in most hospitals, it is the dermatologist who mostly treats patients with these diseases. 2. Treatment and management: Patients with more than mild skin disease are best seen by a dermatologist since: (a) Training: The dermatologist is trained to diagnose, investigate and treat all types of skin disease including occupational aspects. (b) Facilities: Departments of Dermatology have the facilities and support for the full range of investigation and therapies that are required to treat skin disease. (c) Specialist clinics: Most large Departments of Dermatology have a consultant who specializes in the diagnosis and management of contact allergic conditions related to the skin. They are trained to do more than patch testing. Activities include: (i) Patch testing primarily, but also . . . (ii) Prick testing, and frequently, the . . . (iii) Interpretation of specific IgE tests In addition, all dermatologists treat atopic eczema and will be familiar with the IgE-mediated problems seen in many patients with this condition. This will be particularly the case for dermatologists who specialise in paediatric dermatology, as IgE-mediated problems can be especially problematic in children. 238 allergy: evidence
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3. Government policies Allergy Networks/Centres: Dermatologists with an interest in allergic problems in skin disease would be pleased to be members of a network of specialists who treat various allergic diseases. Dermatologists recognise that other specialists may be needed in the management of patients with skin disease that has an allergic basis, eg allergists, immunologists, gastroenterologists and respiratory physicians. Current debates on provision: There is presently much change in the way that services for patients with skin disease are being managed. Generally, the management of more than simple allergic problems related to the skin is a specialist activity that would be diYcult to organise in a care-close-to-home setting. For example, the performance and interpretation of patch testing and prick testing requires a lot of training and experience. Hence the management of patients with this type of problem should continue to be based in secondary care. 4. Patients and consumer issues Referral pathways: Dermatologists are best placed to manage patients with more than mild skin disease, with referral to other specialists in allergic problems as necessary. Some patients with atopic eczema who have severe IgE-mediated problems require to see an allergist. It is a matter of ensuring that the right patient gets to the right specialist with the right problem. 24 October 2006
Examination of Witnesses Witnesses: Mrs Margaret Cox, Chief Executive, National Eczema Society, Professor David Gawkrodger, Honorary Treasurer, British Association of Dermatologists, Dr Clive Grattan, Dermatology Consultant, Norfolk & Norwich University Hospital, and Dr Shuaib Nasser, Consultant in Allergy & Asthma, Addenbrooke’s Hospital, examined.
Q583 Chairman: May I thank you for coming today Chairman of the Standards of Care Committee of the to give evidence to this sub-committee of the Science British Society for Allergy and Clinical Immunology. and Technology Select Committee. The proceedings My interest is in all aspects of allergy and asthma. will be webcast today. I am Lady Finlay and I chair Dr Grattan: I am Clive Grattan and I am a consultant this Committee. All members of the Committee have dermatologist. My base hospital is the Norfolk & declared their interests on a separate document, so we Norwich University Hospital where I see allergy and will not be going through a declaration of interests in I see general dermatology. I also work one day a week relation to diVerent questions today. I would like to at St John’s Institute of Dermatology at St Thomas’ begin by asking you if you would introduce Hospital as part of the cutaneous allergy group where yourselves to the Committee and then we will I am Head of the urticaria clinic. proceed with our questioning. It would be very helpful if you would make sure that you do speak up because, even though there are microphones, the acoustics in this room are not always the easiest. So, Q584 Chairman: I wonder if perhaps—and this will if you could speak clearly, that would be much be principally for the two dermatologists here—you appreciated. Let us begin with you, Professor could describe to us the main forms of allergic Gawkrodger. dermatological disease. Professor Gawkrodger: My name is David Professor Gawkrodger: It depends a little on how you Gawkrodger and I a consultant dermatologist in define allergy but, taking into account what I think SheYeld and Honorary Professor of Dermatology. I the remit of this inquiry is, I would classify the have been the President of the British Contact allergic skin disorders as being atopic dermatitis, Dermatitis Society. I have an interest in contact contact dermatitis, urticaria and drug eruptions. dermatitis and occupational skin problems. I am also There are other skin diseases which have an the Treasurer of the British Association of immunological basis but I think they are probably Dermatologists. not generally regarded as being allergic. Mrs Cox: I am Margaret Cox and I am the Chief Dr Grattan: I agree entirely. It is important though to Executive of the National Eczema Society, a recognise that many patients who present with registered charity which exists to support people who atopic dermatitis often appear to have endogenous have eczema. I also have eczema myself. constitutional behaviour to their disease that appears Dr Nasser: I am Shuaib Nasser and I am a consultant to bear little relationship to allergy and furthermore allergist in Cambridge and I am a full-time NHS urticaria, which is my special interest subject, is often consultant at Addenbrooke’s Hospital. I am also the an internal problem as opposed to an allergic allergy: evidence 239
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser problem and whilst allergy may cause urticaria, there Mrs Cox: I do not think that on an evidence base I are many instances when it does not. could say whether it is right or wrong that the UK is more or less inclined to see these diseases Q585 Chairman: Dr Nasser, do you wish to add in dermatology than allergy, although my anything to that? personal perception specifically by reference to Dr Nasser: The only thing that I would like to add is communications, for example, with my opposite angio-oedema, which is a subset of urticaria, is numbers in the US equivalent group is that such is another skin condition which presents slightly indeed the case. My perception again as far as a diVerently and can occur in association with urticaria patient is concerned is that there is a tendency to get or in isolation and indeed may result from a drug- either into one track, be it the allergy track, or into related disorder. another track, be it the dermatology track, and that possibly in some cases what we are lacking is an Q586 Chairman: Am I correct in thinking that you overlap in the middle. are the lead person on the urticaria guidelines for the British Society for Allergies? Q592 Chairman: Do you feel that there is suYcient Dr Nasser: Yes. We have just completed guidelines credence given by dermatology in the UK to the which are due to be published soon. I should also add allergic nature of some skin diseases? that Clive Grattan on my left is the lead person on the Mrs Cox: I think that it is becoming increasingly urticaria guidelines for the British Association of accepted by the dermatology community, Dermatology, so there is a little bit of urticaria particularly perhaps those who are working with expertise here. children in paediatrics, that there are cases where allergy or allergy-related issues are if not the whole Q587 Chairman: Are those guidelines being written story at least part of it. in parallel and in conjunction to make sure that they Chairman: Would you clarify for us the diVerence are completely compatible? between atopic dermatitis, contact dermatitis, atopic Dr Nasser: We have certainly had some input from eczema, urticaria and angio-oedema. Clive and I know that Clive has written the editorial for the guidelines. Q593 Lord Colwyn: And may I ask on top of that, is adiVerential diagnosis easy or is it diYcult? It sounds Q588 Baroness Platt of Writtle: May we ask when impossible to me. they are going to be published. Are they going to be Professor Gawkrodger: Usually I would say that it is published before our report or after? really quite straightforward to diagnose atopic Dr Nasser: Before, I am sure. dermatitis when it presents in children. If a child develops eczema aVecting the skin folds of the elbow, Q589 Chairman: Would you make sure that we have behind the knees, on the neck or on the face, it is a copy of those as they will be helpful. usually quite obvious that it is atopic dermatitis. It Dr Grattan: The British Association of can be a little more diYcult in adults who present for Dermatologists’ guidelines were published in 2001 the first time with eczema. I think that diagnosing and but a revision is currently under way and will be sorting out dermatitis in adults, say hand dermatitis published soon. or facial dermatitis or foot dermatitis, is quite a complicated business and that is where consideration Q590 Chairman: Mrs Cox, in relation to the of diVerent allergic-based phenomena may come in question about the main forms of allergic because you may need to consider contact allergy in dermatological diseases, is there anything that you addition to a background of atopy which is a type of would like to add? endogenous or internal eczema, and other factors as Mrs Cox: Only one thing, which will I think be a well including external environmental factors. consistent theme for me, and that is that, for the patient, one of the main challenges in this area is in Q594 Chairman: Dr Grattan, do you wish to add fact knowing what you have. to that? Dr Grattan: In relationship to urticaria, which has Q591 Chairman: It has been suggested to us as a not been covered by Professor Gawkrodger, the committee that there is perhaps less credence given to diagnosis is often relatively straightforward to allergy in relation to urticaria and atopic dermatitis the public, the primary care physicians and the or eczema in this country than happens in other parts specialists, but the exact type of urticaria and of Europe where these patients are principally seen by therefore its cause and treatment may be elusive and dermatologists. I wonder if you have any comments this is where there is a need for a specialist with on that. Perhaps you would like to begin, Mrs Cox. insight. 240 allergy: evidence
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser
Q595 Lord Rea: If you look at atopic eczema, is Dr Grattan: I will ask Dr Nasser to supplement what there always a trigger factor or do you suppose that I am going to say, if I may. My own experience is that there is one even if you cannot discover it, or does it it is quite a small number. I see a number of children sometimes come out of the blue for no particular with eczema every week and the parents are often reasons? concerned that allergy is driving the condition and Professor Gawkrodger: Atopic eczema is one of those that allergy is causing specific problems over and conditions which can be very easy to diagnose or above the eczema. I think that the number of times I quite diYcult. There are many, many diVerent things can confirm that is probably no more than 10 per which feed into it and partly there are strong cent, but that is a personal view and remember that constitutional or genetic factors, so inheritance is this is a population of patients referred to a often a strong thing. It is associated with other dermatologist rather than an allergist. disorders such as asthma or hay fever rhinitis and Dr Nasser: The first thing that I would like to say on some people do have a previous history of these this issue is that eczema should really be regarded as a things. If somebody develops an eczema in symptom rather than a disease with many underlying adulthood, they may have a past history of eczema as causes of which allergy is one. So, you can have a child which cleared up and then something comes patients with eczema who are completely non-allergic along, say they develop hand dermatitis, and, in those and do not have any allergenic triggers and others in sort of instances, it would be important to look for whom allergy does play an important role, and it is some triggering factor which may be occupational, so important to try to tease out that group because if they may be exposed to some environmental factors you can get them to avoid certain allergenic foods or that have brought their eczema out and that could be aeroallergens, then you can improve their symptoms. wet work or exposure to a cold or hot climate and In terms of overlap, we know that one of the first there can be other things such as stress and allergy for manifestations of allergic disease (and by that I mean example contact dermatitis, but there may be some food allergy, asthma and hay fever) is in fact eczema internal factors as well and it is quite well recognised and I regard the surface of the skin as a portal of entry that, for example, in students who are undertaking for allergic sensitisation. So, it is not just the examinations, their eczema may get worse at the time forerunner, it is actually an important underlying of their exams because of stress and stress makes factor leading to food allergic sensitisation and also them rub their skin which brings out the eczema. asthma and hay fever. So, there is a large overlap and Having said that, even despite looking for triggering certainly patients presenting to an allergy clinic are factors and investigating for allergic problems much more likely to have these overlap diseases. which may include patch testing and also blood tests for immunoglobulin E levels and specific immunoglobulin E levels, you do not always find the Q599 Lord Taverne: Coming back to an earlier triggering factor in every case. question regarding how treatment and diagnosis of dermatitis compares with other countries, Mrs Cox said that she had some comparison that she could Q596 Chairman: How often do these conditions make with the United States. Can any of you throw coexist in patients? any light on how we compare with the continent? Professor Gawkrodger: Do you mean asthma, hay Professor Gawkrodger: One problem that we have in fever and eczema? the UK is that we have far fewer specialists—that is not just for dermatology; there are far, far fewer specialists in allergy for example—than most of the Q597 Chairman: I was thinking of the diVerent skin countries in Europe. Germany has several thousand manifestations such as urticaria and eczema. dermatologists and the same in France and Italy. We Professor Gawkrodger: I think I will let Clive answer only have 500 consultants in dermatology and far the one about urticaria. fewer consultants in allergy. In Germany, for Dr Grattan: Usually, urticaria is a stand-alone example, a number of dermatologists have more than disease but, in children with atopic eczema, it is one qualification, so they have a qualification in possible for them to react with urticaria to allergens dermatology and they are also qualified in allergy as including foods and maybe animals or plants, so well. I think that the combination of these two things, there is overlap. Most patients who present to the fact that they are more widely qualified in hospital clinics with chronic urticaria—and this Germany and there are many more of them, perhaps implies continuous disease for at least six weeks— 7,000 dermatologists in Germany compared to just have a stand-alone disease. 500 in this country, perhaps means that they are more prone to investigate patients with some eczema and Q598 Chairman: How often do children with eczema urticaria than the average dermatologist might do in have other manifestations of allergy? this country. Having said that, I think that it might allergy: evidence 241
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser also be true to say that British dermatologists might Professor Gawkrodger: That is really quite a complex have something to learn from their continental question. When it comes to the environment, there counterparts in perhaps taking a wider interest in are a number of interactions between the skin and the IgE-mediated allergy than they presently do. environment because the skin is really the first barrier of the body and the immune system, so the skin is actually there to protect you from the environment Q600 Chairman: If I may follow on from that, how but it is there to be damaged by the environment as adequate are the services to enable allergic triggers to well. If you have any sort of skin disease, then there be diagnosed amongst patients? Is there a cohort of are certain environmental factors that may make it patients there who currently are not accessing the worse. The exact factors that might worsen almost appropriate diagnostic services to detect an allergic any sort of skin disease might be diVerent. If you trigger to their skin diseases? think about atopic eczema and you just consider Dr Nasser: The answer is “yes”. There are very few what external environmental factors might be specialist allergy centres in this country as you will be playing a part, then you have things that are non- aware from previous hearings. There are something specific irritants such as wet work, wind, cold, heat, like six full-time specialist centres dealing with dryness and other environmental things like that, and allergic disorders and perhaps only 30 full-time you have frictional things which may be rubbing of equivalent allergists compared to a couple of the skin or rubbing of frictional materials against the thousand in, say, Germany. In terms of being able to skin, and you also have chemical allergy as well, access an allergic diagnosis for your eczema, you are chemicals that come into contact with the skin either actually very unlikely to be able to achieve that and applied by the person themselves or which they have eczema is a very common disorder as are all the contact with at work may actually induce either an other allergic diseases. Food allergy is increasingly allergy or produce an irritant which has a type of V common as is hay fever and asthma. It is not just the toxic e ect that is not allergen mediated. Whether milder forms, but in fact the more severe forms of you develop a contact dermatitis or not depends on a V these disorders that are seen increasingly. So, it whole number of di erent factors. It can depend on depends where you live whether you can access these the actual chemical structure that comes into contact with your skin. For example, they tend to be small services. There are some dermatologists who are sized molecules which tend to be more allergenic than interested in both aspects and Clive Grattan is an large ones but not always, it depends of the example. So, there is a considerable overlap but there concentration, the solubility of the chemical in water are many dermatologists who are not able to access or liquid and it depends on your personal allergy services at all. predisposition to become sensitised which varies between diVerent people. I think probably I will stop Q601 Chairman: Mrs Cox, would you like to answer there having said a fair bit and let somebody else have that from the patient perspective. a go. Dr Nasser: We have heard about the non-specific Mrs Cox: I would agree wholeheartedly that, from triggers and, certainly if you have eczema, then non- the patient perspective, where you live makes a huge V specific triggers will aggravate the eczema and a di erence and that many patients are not able to classic example is swimming in chlorinated water access an allergy related service for their eczema. I which will often aggravate patients’ eczema. There would also add that, in consequence, what is tending are some specific triggers and specific allergenic to happen, particularly with parents of children with triggers for example latex, and wearing latex gloves eczema, is that they are guessing around allergy, they can aggravate patients’ pre-existing eczema. I saw a are frequently guessing that it is diet and they first-year veterinary student yesterday who had to are tending to embark upon do-it-yourself diet leave her lesson because contact with a horse within avoidance which in many cases is probably not going minutes aggravated her eczema, so much so that she to impact upon the eczema but might well impact on was unable to stay, and it had happened to her on a the overall well being of the child and meanwhile the number of other occasions. There are many factors eczema itself remains untreated. that can aggravate eczema. In a proportion of patients inhaled allergens, for example animals and house dustmite, are important allergens. Also, in the Q602 Lord Haskel: May we move on to the environment, I suppose you could add infection. environment and ask you what environmental Certainly infection will aggravate eczema and that is factors contribute to the development and something that is often not appreciated especially in exacerbation of diseases like atopic dermatitis, primary care. eczema and urticaria and whether there are any Dr Grattan: I think it would be worth at this stage environmental measures that we can take to prevent making clear that atopic dermatitis and allergic these disorders developing. contact dermatitis are completely separate 242 allergy: evidence
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser conditions and the replies you have had to some not know what is going to happen in, say, 10 years extent merged those two illnesses together. Atopic time. Another area of concern is hair dye. That is a dermatitis may have a genetic component that allows chemical called paraphenylene diamine which is people to develop it in addition to asthma and hay virtually the only chemical which will actually dye fever and there may be environmental triggers and hair. It is present in up to six per cent concentration factors as we have heard. Allergic contact dermatitis in hair dye and, with the increased frequency of hair on the other hand can happen to anybody. I do dyeing—up to 70 per cent of women and up to 20 per not believe that there is an underlying genetic cent of men actually dye their hair—and with predisposition. Also, it depends on the concentration younger and younger age groups of people dyeing and prolongation of exposure to the chemical their hair for fashionable reasons, allergy to hair dye allergen whether or not sensitisation and an allergic is quite a concern and I think probably warrants skin disease develops. I think it is important to further inspection as to whether there are alternatives separate those two and discuss them separately. and whether it is actually safe. On a European-wide Professor Gawkrodger: I do not entirely agree with you basis, certain preservatives which may produce a there in that an awful lot of people who will be contact allergy have been banned because they have developing an allergic contact dermatitis actually caused too many problems. I think that legislation have an atopic background. I think that you have to can be helpful in limiting contact with problem look at the patient in the round and, when I conduct chemicals. my contact dermatitis clinic, I want to know the atopic status of the people I am seeing. In addition, Q604 Lord Taverne: With the very widespread I think that there is a genetic predisposition towards fashion for hair dyeing, has there been an equivalent being sensitised to chemicals in terms of allergic increase in the number of allergens? contact dermatitis. I think that some people become Professor Gawkrodger: It appears that there have been. sensitised and some people do not. There are genetic I cannot quote you the publication oV the top of my factors which I would say we do not fully understand head. The problem with paraphenylene diamine is that are playing a part. that you can get very severe reactions. You can get severe swelling of your face and neck requiring you to Q603 Lord Haskel: What measures can we take to have treatment with systemic prednisolone to get it prevent these disorders developing? We can just down. I believe that there has been an increase. I simply avoid food allergens or possibly house cannot quote you the exact paper but one of the dustmites, but there are a number of things which we problems is the severity of the reaction. cannot avoid in the environment such as fragrances, cleaning fluids and this sort of thing. Is there Q605 Lord Haskel: What about non-clinical things anything we can do to prevent this such as the pre- like air conditioning which we are all subjected to? testing of products and that sort of thing? You mentioned that infections were a cause. Can we Professor Gawkrodger: There is European legislation do anything about the quality of the air or something on this matter and I would refer you to the European like that? legislation on chromate in cement which is Professor Gawkrodger: When it comes to the area of particularly important for hand dermatitis in air conditioning, it is diYcult to say whether it causes construction workers. The chromate sensitises problems with their skin. I do ask people about that people and they develop a chronic hand dermatitis, and I think that sometimes, if you have a tendency to and there is some evidence that reducing the amount get dry skin, excessive air conditioning may actually of available chromate in cement by adding ferrous make your skin worse, but it has not actually, as far sulphate has actually reduced the incidence of that. as I am aware, been very well researched. There is European legislation on the amount of nickel Dr Grattan: May I expand a little on the hair dye in jewellery and there is some evidence that that has sensitivity prevalence. There is some information on reduced the evidence of nickel allergy which may that and it is contained within a document which I be associated with certain types of dermatitis. In believe has been submitted to this Committee and is addition, European legislation on the labelling of therefore before you. I can read it if you wish. fragrances or labelling of the ingredients in cosmetics has come into play and that has been very useful because we can advise patients whom we diagnose as Q606 Chairman: Are you referring to the BMJ being allergic to certain things to avoid these things. editorial with all the references in it? I would share your concern about our wider exposure Dr Grattan: Yes and there is a further document to things like fragrances and it is particularly which has been produced by my colleagues I believe worrying in children’s products where children are at St John’s Institute of Dermatology which contains being exposed now to a lot of fragrances and we do that information. allergy: evidence 243
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser
Q607 Chairman: Yes, thank you. key thing. We will ask whether there are any Dr Grattan: There is one other area of avoidance triggering factors and I ask people if they think that which has been a success story and that is powdered there are any foods involved. It depends a little on the latex gloves for healthcare workers. It was recognised severity of the eczema. If it is somebody with mild some years ago that having powder within latex eczema that can be easily controlled, I think that we gloves appeared to be linked with the increasing will not probe too deeply. If it is somebody with more incidence of latex allergy and, since powder has been severe eczema, we will certainly look for whether banned, at least in Germany and I think thoroughly there may be a contact dermatitis complicating the discouraged in the UK, the incidence of latex allergy picture, in which case patch testing would be part is falling. The investigation into latex allergy of the work-up and, in my department, we do does also illustrate the overlap between allergic actually patch test people with atopic eczema to contact dermatitis and urticaria which Professor aeroallergens. I certainly would take blood Gawkrodger was talking about and I separated them investigations for immunoglobulin E and I might out for simplicity only but, as an example, someone actually look for some food allergies if the patient who reacts to a rubber glove may react to the natural had given a very strong history of food allergy. I latex protein with an allergic mechanism which is think I might be going beyond what the average Type I and relates to eczema, asthma and hay fever, dermatologist would do there because I have a or to the chemicals used to cure the rubber and then particular interest in allergy and the skin. As to why that would be the Type IV mechanism which would British dermatologists do not do such a major work- be diagnosed by patch testing, so there is an overlap up—and I would agree that they do not in most of dynamics for the treatment of patients and their cases—I think that perhaps part of the answer is condition. pressure of work with there being only 500 dermatologists and another aspect is also availability Q608 Chairman: Mrs Cox, would you like to come to undertake allergic investigations particularly for in at this point? prick-testing which is quite a time consuming Mrs Cox: Looking at this in an overarching way, I investigation—that is where you prick in the suggest that there is a tendency for us to hugely allergens into the arm—but maybe also that there is underestimate the importance of our skin as our a trend for British dermatologists not to regard an barrier to the outside world and a need for people to allergic input into the dermatitis in the same way as have a better understanding of the need to protect people do in perhaps Germany in most cases. their skin and, to the extent possible, not to go into total avoidance of everything but to be sensible about what they put on their skin and perhaps, more Q611 Lord Colwyn: How is it in Norwich? importantly, their children’s skin and not to be Dr Grattan: I also have an interest in skin allergy and tempted into thinking that everything which is promoted as being “good for your skin” and “good I think that one of the limiting factors that I for your baby” is actually good for either. experience and many of my colleagues experience is oVering patients suYcient time. Certainly, a full consultation may take at least 30 minutes and for Q609 Lord Colwyn: Some of us went to Germany to more sophisticated allergy problems 45 minutes. The take some evidence—unfortunately I had to miss the structure of clinics often precludes allowing that trip—and there we saw the dermatologists do what is amount of time, and from history flows the described as an allergy work-up for atopic dermatitis investigations and I would direct at problems that I and urticaria. Can you tell us whether all identify from the history as opposed to giving a dermatologists do this in the UK and, if they do not, battery of tests to everyone. why do they not? Mrs Cox: Could I add that what we are hearing here Professor Gawkrodger: I am not sure what the work- is experience in relation to secondary care and in fact up was. Are you able to say what it was? hugely the majority of patients with atopic eczema will be seen in primary care and, in that environment, Q610 Chairman: We heard from the allergy clinic very few, if any, will have any allergy issues there that they go through an exclusion process investigated at all and fairly obviously time is a actively looking for allergens. huge factor. Professor Gawkrodger: I think that is probably not Chairman: We have spent quite a lot of time on this common practice in the UK. Certainly in my first bit of questioning and we now need to speed up. department and with my colleagues, I think when it I will now move to Lord Taverne and ask you to keep comes to somebody with, say, atopic dermatitis, we your answers concise and we will be able to move will take a history and I think that the history is the through all the other questions that we have. 244 allergy: evidence
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Q612 Lord Taverne: How many people in the United Dr Nasser: Maybe I can talk a little about that. I have Kingdom currently suVer from atopic dermatitis, certainly come across SNOMED but it is at an atopic eczema and urticaria and how has the embryonic stage so it is not yet being used. The incidence of these diseases changed over recent years? principle is that every allergy patient has a diagnosis Professor Gawkrodger: With regard to atopic recorded, but it is important that the correct dermatitis, at the present time, about 20 per cent of diagnoses are placed into the system in the first place the children have atopic eczema and that is an which can only happen if the doctor is appropriately increase compared to about 50 years ago we suspect, trained in allergy. although really good studies previously were not actually done. Of those children, I would say that approximately 50 per cent will grow out of it in their Q615 Lord Colwyn: May we move on to some of teens which leaves you with 10 per cent of adults who the treatments now. Can you give any common will have atopic eczema to a greater or lesser extent, treatments such as antihistamines and and it may be very mild in terms of just some dryness corticosteroids that are used and say whether you of the skin or it may be very severe, it varies. I will let think these actually cure anybody. someone else answer about urticaria. Professor Gawkrodger: With regard to atopic Dr Nasser: Dealing with atopic eczema, there are dermatitis, the treatment will depend on the severity some studies that show a threefold increase in the last of the condition and also where you are seen. If you are seen in general practice with mild eczema, I think 20 years or so and there is a Welsh study which in V 1973 showed a five per cent incidence of atopic that first of all you would be o ered moisturiser eczema amongst 12-year olds and by 1988 that had emollient which is a cream which can help to treat the gone up to 16 per cent. There are other international dryness of the skin which is one of the primary studies and there is a very good study, the ISAAC, symptoms along with itching and also emollient for the International Study of Allergy and Asthma in the bath or for showering with. If it were more than Childhood, which looked at both cohorts, and they just mild eczema and non-responsive to an emollient, then the plan would be to move on to a topical steroid found a 22 per cent prevalence of atopic eczema. So, V we know that these diseases have increased of which there are di erent strengths from mild to enormously in the last 15 to 20 years and I would moderately potent to highly potent and it is usual to certainly go along with the fact that many of these start with a mild one such as hydrocortisone and patients do not have resolution or they do not grow move on to a stronger one if necessary. Any infection out of their symptoms into adulthood although the that is present, which is not an uncommon thing, severity of the condition may have improved. should be treated as well. If the patient does not Dr Grattan: The prevalence of urticaria is eVectively respond at that stage, the usual thing is to refer on to unknown because there are no good studies that secondary care and there they may try a stronger looked at this. Estimates range from as high as 30 per topical steroid for a longer period of time, perhaps cent of the population of a country being aVected by considering other things that might be involved and one form of urticaria or another over their lifetime to that is where considering other allergic problems as low as one per cent, and good data are needed. I might come in. There are other topical treatments cannot tell you if the incidence has gone up. It may apart from topical steroids and these are called have but I do not know. calcineurin inhibitors, and they do not have the same side eVects as topical steroids, things like tacrolimus. If people do not respond at that stage, probably Q613 Lord Taverne: Who records the number of another thing that happens is that the team will look V people su ering from these diseases? at the compliance of the patient, so is the patient Professor Gawkrodger: Nobody records them applying his/her cream properly, and it is very Y o cially. Any sort of study is a research important to look at that. This is a common reason investigation. why patients do not get better and it is where nurse practitioners are useful at improving patient care. If Q614 Lord Taverne: The Department of Health said these topical treatments do not work, then it is on to that there are currently problems regarding the data systemic therapy which is quite a big step because you collection of allergic diseases and they hoped that the are on to quite potent immunosuppressive drugs introduction of a new nomenclature system, which which can have quite serious side eVects but which they elegantly describe with an acronym called can be very helpful for people with the very most SNOMED, would enable allergy to be classified severe types of eczema. more specifically when clinicians enter data on to Mrs Cox: Clearly, I would not disagree with that but patient records. Do you think SNOMED will enable again I would like to remind everyone that in fact the prevalence of allergic skin diseases to be more most eczema patients are seen in primary care. accurately recorded? Certainly in my experience referral out of primary allergy: evidence 245
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser care into secondary care can be very hard to achieve. not been terribly good, unlike for rhinitis or for some I do agree that compliance with topical treatments is studies in asthma. not always too good but there are several reasons for that, one of which may well be, particularly in the Q619 Baroness Platt of Writtle: What you said just primary care environment, that nobody has really now about no curriculum position for training had the time or possibly the expertise to show the doctors was very interesting, but is that perhaps one patient or the parent how to apply them in the first of the most important things that ought to happen? place. Dr Nasser: The most important thing. I am glad you picked it up. It is probably the most important thing Q616 Lord Colwyn: Are there many patients who do that should come out of the Committee’s findings. not respond to these treatments? Are you able to give Y a rough percentage? I know that it is di cult because Q620 Lord Colwyn: Do the treatments vary with there are varying degrees of the illness. children and how does the school environment deal Professor Gawkrodger: I could not give you a figure with this? but I would say that, in all of our clinics as consultant Mrs Cox: In the school environment, as so often dermatologists, one of the most regular things we see happens, truthfully it is hugely variable. Issues that is people on systemic treatment for their eczema, so are commonly experienced by children with eczema there is a quite a lot of them, but I cannot say exactly in school tend I think to stem from a failure to take what proportion of people with eczema as a whole eczema terribly seriously combined with the fact that have to have systemic treatment. It is certainly a it requires frequent topical treatment which of course minority. can be very diYcult to achieve particularly at the younger age. Q617 Lord Colwyn: Can you say something about allergen immunotherapy. Q621 Lord Rea: I wonder if you could deal a little Professor Gawkrodger: I cannot myself. more with the training of general practitioners. How do you think this training could be improved either as Q618 Lord Colwyn: Can it be used to treat atopic undergraduates or perhaps as postgraduates? In dermatitis or urticaria? primary care, what proportion of patients is referred Dr Nasser: That brings us on to curing the condition to specialists in allergy or dermatologists and which? Dr Nasser: and that is really what your question is aimed at. We The first thing I would say is that, if you have heard about lots of pharmacotherapy and the look at the curriculum for most undergraduates, question that arises is, are there any allergens first of there is hardly any teaching on allergy and there is all that you can avoid which may improve symptoms certainly no structured teaching. It may be given as and other than irritants, are there any chemicals that part of an asthma lecture, for example on one slide, you can avoid as this aspect of the management is but there is certainly no structured teaching in also very, very important? One of the things that allergy and there are so many other demands on patients eventually come to realise is that, when the the curriculum at the moment in terms of eczema is severe, it is very diYcult to improve, but, communication skills etc that some important when it is good, it is easy to maintain its status. So, it aspects of the curriculum do not actually make it into is important that patients understand that. One of the training. Unless that is remedied, we are not going to things that we try to do as allergists is to identify get general practitioners who understand anything underlying causes in the proportion of patients who about allergy at all. The second aspect of the question have an allergic cause, and these may be I think is the postgraduate training and, because aeroallergens or food. Certainly that can lead to a there are so few allergy specialists in the country, reduction in the pharmacotherapy, some of which there is no one to undertake teaching. Certainly in have very severe side eVects. You asked a question our area in the eastern region, we undertake quite a earlier about the diVerence in management in lot of teaching and I suspect that our general diVerent countries and the simple answer to that practitioners are better educated than in any other question is that there is no education in English or parts of the country, but that is something that British medical schools on allergy, so there is no cannot be rectified unless there are centres with curriculum on allergy and that is why our general allergy specialists. What was the last part of your practitioners have very little understanding of the question? subject, and I think this is a very important point. Immunotherapy is not eVective in eczema on the Q622 Lord Rea: The question of whether to refer to whole. I know that people have tried immunotherapy dermatologists or allergists if somebody has atopic for eczema but, as far as I am aware, the results have dermatitis and urticaria. 246 allergy: evidence
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Dr Nasser: I would say that only a very small Q625 Earl of Selborne: If you are going to increase proportion of patients get referred. There are the provision of training to GPs and others, does that increasing pressures in primary care not to refer imply that you have specialist clinics or does it imply patients into secondary care and these are pressures a peripatetic training which goes round to the GP that have come on in the past six to 12 months practices? because of cost, and because of the great debt that Dr Nasser: I think a bit of both. I would be supportive PCTs find themselves in. My wife is a general of both things. There is so little knowledge in primary practitioner, so I can talk about this subject—and care that we should do both. certainly there are internal pressures to refer as few patients as possible to hospital. Q626 Lord Taverne: Since we have a shortage of teachers who can train, is this a case where we should Q623 Lord Rea: As a former GP, my problem was import the expertise from abroad, if we can get it? Dr Nasser: that there were diYculties in referring people to I would not be a fan of that. I think that allergists because there was a very long waiting we should develop the expertise within our own list, six months or more, and it was easier to refer trainees. Certainly it could be a short-term measure to a dermatologist something which perhaps but again we have to think long term about this. appropriately should have gone to an allergist. Dr Nasser: I am sure that is right. The waiting lists are Q627 Chairman: Is there an adequate use of modern coming down but, unless you have an allergist in your education methods such as e-learning and distance locality, you cannot refer patients. learning in the subject? Dr Nasser: Yes and I am sure that that is something that could be employed. The question is, how Q624 Earl of Selborne: I want to come in on this eVective would that be simply because I think that the rather familiar story but a very depressing story that most eVective training is from seeing patients and, Dr Nasser was spelling out that patients see GPs and unless it is ingrained from the very beginning that indeed nurses, dieticians and the people at the allergy is an important aspect of many disorders, for frontline, the people to whom most patients are example asthma and atopic dermatitis, then it is referred, and do not go much further and yet, as you unlikely to succeed. E-learning is certainly taking oV. point out, the knowledge of GPs and indeed others is I do not know how eVective it is. really very poor. Addressing the curriculum at undergraduate level is not going to solve the problem, Q628 Chairman: Do any of the dermatologists want is it, or not for a generation or two? Would you have to comment on the eVectiveness of e-learning? any radical thoughts as to how this great omission Dr Grattan: I would be happy to comment but may I could be addressed? What structure would you like to steer the discussion back a little to the education of see put in place to allow GPs, nurses, dieticians and GPs in dermatology. Although dermatology is on the other people like that to get a grasp of these issues? undergraduate curriculum, it is often allocated a Dr Nasser: I would say two things. The first is that we relatively short period of time and there is no have to look long term and sort out the problem from compulsory postgraduate training of general the beginning, so that has to be thought of as an practitioners in dermatology that I am aware of. important aspect of introducing allergy training into However, they do get education on rotational the undergraduate curriculum. So, we must think training schemes when dermatology is included as a long term. In the shorter term, I think what can be specialty. My own experience is that they find this done is that we must educate our primary care extremely valuable. This might be a way forward physicians and the way in which you do that is by with allergy if allergy were to be included on GP conventional means but, unless you have a local vocational training schemes where that expertise is allergist, you cannot do it. So, the best short-term available.46 solution to that would be to increase the number of Chairman: Would you like to comment on that, trainee physicians in allergy in order to create more Mrs Cox? centres that are able to deliver teaching. There are Mrs Cox: I believe that there is some limited large parts of the country that will have very little availability of postgraduate training in dermatology exposure to an allergy clinic. So, in the short term— but I would agree with the overall point, namely that, and by that I mean four or five years—you can on the whole, when you go to see your GP with atopic achieve that simply by increasing the number of 46 Most departments of dermatology in the UK oVer programmes trainees but, in the longer term, I think it is essential of postgraduate education for General Practitioners for the that allergy, which is one of the most frequently purpose of CME (continuing medical education) credits but only some GP’s will have the opportunity of a formal training encountered illnesses in general practice, is entered in Dermatology as an element of their Vocational Training and into the undergraduate curriculum. this should be encouraged. allergy: evidence 247
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser eczema, you will be extraordinarily lucky if your GP Dr Nasser: Well, latex allergy is actually one of the has had any significant training in dermatology success stories and it is an example of where and even luckier still if that training is anything Government and Department of Health intervention remotely recent. has actually improved matters. In Cambridge we have had a written hospital latex policy with patient Q629 Baroness Platt of Writtle: I am just thinking at leaflets for at least six or seven years and we have seen what level the people who do the training would need a decline in the number of referrals of patients who to have a qualification. I understand that GPs are are essentially health care workers, but also people in having CPD, it is part of their on-going qualification; other industries, and the number of referrals has could the allergy skills be included there? How do we come down considerably. The main reason for this is train the trainers? the written policy and also the fact that we got rid of Professor Gawkrodger: I think when it comes to powdered gloves many years ago. Up until recently training GPs and specialist registrars, all consultants the National Patient Safety Agency identified that up are trainers so there is no problem; any consultant to 40 per cent of health care institutions did not have has to train a registrar and can train GPs. a written latex policy and they have now made it compulsory for every health care organisation to have a written policy, which I think had to be done Q630 Baroness Platt of Writtle: But there is a within the last few months. I am sure that this will shortage of them? further reduce the number of people with latex Professor Gawkrodger: I think perhaps one of the sensitisation. points that could be made there is that there is not enough attention given to time set aside for training in consultants’ job plans because consultants’ job Q633 Lord Selborne: I wanted to ask about plans have now been squeezed and squeezed to occupational diseases. Could you tell us what reduce the amount of time there for training people— proportion of patients suVering from skin allergies and for research, I might add—and to increase the have developed their disorder due to conditions at proportion of the time spent in clinics and seeing work? Perhaps you could tell us what occupations are patients, which is where the target-driven ethos that most commonly aVected by allergic dermatological now pervades the NHS comes into play. I would like conditions and what could be done in the workplace to just support the views of my colleagues here in to prevent the development of these disorders? saying that GPs need far more training in Professor Gawkrodger: Firstly, with regard to the dermatology and allergy than they currently get, and proportion of patients that have developed their skin there is no doubt the best way of getting that allergy from occupation, it is not known. The number experience is for specific training posts for general of patients who have occupational skin disease, practitioners to include an element of dermatology which is almost all dermatitis, is just over 100,000 per and allergy within the training. year by an estimate from the EPIDERM Unit at Manchester University. Of those, up to 50 per cent will have a contact allergy as part of their problem. Q631 Lord Colwyn: Do you think the GMC might That is about the best figure I can put on it. The ever make it compulsory as part of CPD to do certain commonest occupations to figure there—and I think aspects of medicine? it is best to look at the proportion per occupation— Professor Gawkrodger: Training is regulated by one of the highest ones is hairdressers. Hairdressers something called PMETB—the Postgraduate are a particular problem because they have very poor Medical Education and Training Board—and the access to occupational health services and they work exact components of training are determined by that in very small firms and the message about good hand with influence from the Royal College of General care, avoidance of allergens (of which there are Practitioners. several in the hairdressing industry) and also sensible Chairman: I want to move on with some of our glove use does not get through as well as it should. Of questions now. Lady Platt? the other industries, the ones that appear in the top five include the chemical and petroleum industry, the Q632 Baroness Platt of Writtle: Patients suVering construction industry, health care workers and from latex allergy often experience diYculty in people working in agriculture. As regards what can obtaining medical care due to the contact with latex- be done to prevent it, I think there are a number of containing articles such as gloves or vial stoppers. things and some are legislative, as I mentioned What information is available to these patients when before, for example the limiting of chromate in they enter hospitals, health clinics—and I had better cement is an important thing, and getting the message add or GPs’—and how could awareness of the through about being careful when handling toxic potential risks be improved? chemicals because very commonly people handle 248 allergy: evidence
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser chemicals in an inappropriate way and they do not under-estimates and over-estimates. It under- wear the appropriate personal care equipment, and estimates because there is general under-reporting better education of the workforce can go a long way and under-recognition of occupational skin to improving matters there. Also I would agree that problems, but it can also over-estimate the there should be the proper use of the correct type of importance of an allergen because you only have to gloves. Perhaps also people who may be inclined to have suspicion that it might be involved to report it, develop eczema, perhaps people with an atopic and it does not need to be verified by somebody who eczema past history should not go into certain knows the answer. I think the biggest problem about occupations where they are likely to develop the gross under-reporting of occupational dermatitis problems, for example hairdressing, which has got a is the problem that general practitioners cannot lot of wet work involved in it, tends to make people recognise properly, because they are not educated with a past history of atopic eczema develop severe suYciently, when occupation is playing a role in hand dermatitis which then means they have to leave somebody’s skin problem. It is not recognised the job. enough. What you can do about it is a very diYcult thing to answer. I think the best way of getting a really pure answer to it—and it is really a research Q634 Lord Selborne: It is interesting, is it not, to question—is to take a defined population out there in reflect that where you have got a large, structured the community and look at it in great detail by people organisation such as the hospitals you get the success who can truly recognise and investigate for an stories which we have just heard about with the latex, occupational skin problem and then somehow and then you refer to the small businesses of translate the results you get on a national basis, but hairdressers or farmers, where presumably it is much that has got problems as well. harder to impart this information. Do you think that there are any other success stories? Is for example the National Hairdresser Day which we have heard Q636 Lord Rea: There is a problem in distinguishing about likely to impact on this problem, do you think? objectively whether allergic disease has an Professor Gawkrodger: I get the impression that the occupational origin or not. I believe that the Health hairdressing industry is taking the message on board and Safety Executive has suggested that there should about better hand care and more sensible use. They be standardised criteria introduced which might help are a very diYcult group to reach, but I think the measure the trends in these diseases. Professor Gawkrodger: Health and Safety Executive have got a project on Yes, at the moment the way we say whether we think somebody who is exposed to a this in mind and I hope that it will make a diVerence. certain chemical whether that chemical is an occupational chemical or not, is once you have Q635 Lord Rea: We have heard about the Centre shown on patch-testing that they are allergic to it, for Occupational and Environmental Health at once you have demonstrated the allergy, then we say the University of Manchester which records the are they exposed to it, and if they are exposed to it we incidence of occupational dermatological diseases as more or less say, well, in that case we think it is part of the OPRA and EPIDERM projects. Would playing a part. I agree that a better definition of the you perhaps spell out what those acronyms stand for? situation would be helpful. I gather these projects have been criticised because they suVer from under-reporting, and I think you Q637 Lord Taverne: Can all dermatologists referred to that. How could the recording of adequately treat patients suVering from a disorder occupational allergic diseases be improved? with an occupational cause or is there a need for a Professor Gawkrodger: The OPRA scheme is the small number of subspecialists? reporting scheme for occupational physicians and the Professor Gawkrodger: All dermatologists are trained EPIDERM scheme is the reporting scheme for in contact dermatitis and that will include some dermatologists. Yes, the problem about these training in occupational skin problems, so if it is schemes, as you mention, is that they are selected a relatively straight forward occupational skin reporting. In both schemes there is a core group problem, such as somebody is allergic to rubber of reporters who report every single case of chemicals in rubber gloves or latex or to chromate, occupational skin disease that they see, but then also then it should be within the capability of the average there is a sampling group who only report for one dermatologist. If it is a rather more complex case, month every year, so the figure of the number of then it may not be and it may require somebody who people who have an occupational problem is a figure is specifically trained and has specific expertise in that has been produced by multiplying a number of occupational skin disease, of which there are a other figures, and so it is an estimate not a firm figure. number of people in the major centres, so I think if Another problem with the scheme is that it both you take the major centres in the UK, the big cities allergy: evidence 249
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser with the large departments, you will find one person were funded on urticaria. When it comes to the major there or sometimes more than one person who does funders like the MRC or the Wellcome I am not take a specific interest but you are then only talking aware at the present time, although I have not about 20 or so individuals. I personally do favour checked with them specifically, that they are funding that because the subject of occupational skin disease any research on atopic eczema or other aspects of is becoming more and more complicated and I think dermatitis. I do feel that it is an under-researched it would be the best way forward. area. One problem that we have in dermatology is Dr Grattan: I would support everything that I have that funding for research in dermatology comes quite heard and I think that specialist groups who have a long way down the pecking order in comparison particular experience in occupational dermatology with funding for cancer and cardiovascular disease, and patch-testing should be promoted and for example, and there has been erosion of encouraged. The subject of dermatology is becoming the university bases. University departments of more diverse. Skin cancers are becoming more dermatology have been merged into larger common. Practitioners are being asked to do more departments and in some cases the departments have things than ever before and there is a future risk of actually closed. The two major departments in training skills in, say, patch-testing and occupational Liverpool and Glasgow have actually closed over the dermatology becoming diluted by the requirement to last 10 years, so academic dermatology has been do other aspects of dermatology, so even having under a big threat generally. centrally funded posts that recognised the importance of this would be helpful. Q641 Lord Selborne: Do you think that there is adequate international collaboration on the Q638 Lord Taverne: In the case of occupational research? asthma, a Group of Occupational Respiratory Professor Gawkrodger: Certainly major research Disease Specialists (GORDS) convened regularly by groups do look to collaborate internationally, the Health and Safety Executive aims to develop a particularly within Europe. I think that generally standard of care document for diagnosis. Would it be speaking there is insuYcient research on the subject useful to have a similar document circulated for of eczema and atopic dermatitis, even at an dermatitis? international level. Professor Gawkrodger: I am not aware of the Dr Grattan: The situation with urticaria is even worse document on asthma, but I certainly would agree than you have heard for atopic dermatitis. There is that better definition of the problem and greater little active research in the UK and internationally awareness would be helpful. less attention is paid to urticaria than other diseases of similar prevalence. This does have consequences Q639 Lord Taverne: Dr Nassar is perhaps aware of for me as a clinician advising patients who come to the GORDS approach? me often from all over the country to the tertiary Dr Nasser: I am and like with any written guidelines referral clinic at St Thomas’. They want to know why it is always helpful to have a set of standards because and they want to know what to do and I often have you can then compare the incidence of a particular to respond by my instincts and my experience but not disease from one year to the next knowing that you by written evidence, so I often have to treat patients have used the same set of standards, otherwise you with unlicensed remedies that have not been fully have many practitioners up and down the country evaluated. There is a major need for better research using perhaps diVerent standards so I guess that and recognition of the importance of this subject. would be helpful.
Q640 Lord Selborne: I was going to ask about Q642 Chairman: Is that because there is nobody research and we have already heard as an aside that interested in taking the lead or is it because there are research and training have been squeezed by cost- people who are interested in applying for funding but cutting. Could you tell us what research is currently just not getting the funding? being carried out into atopic dermatitis, eczema and Dr Grattan: I think it is probably lack of interest in urticaria in the United Kingdom and who carries it people taking the lead as a whole. We have many out? Is it declining? pressures on us to accomplish service work and I Professor Gawkrodger: The major funder of skin think that funding is perhaps an issue. I can give you research in the UK is the British Skin Foundation. I my personal experience very briefly that I have now did check with them last week and over the last nine an allergist from abroad who is working with me and years or so they have funded 139 projects of which 12 will be for three years, doing what I hope will be a were on atopic eczema and 10 were on dermatitis. very useful and enlightening series of projects, but she When it comes to funding I could not see any that is funding herself to come and work with me and I 250 allergy: evidence
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser have to give my time outside my service commitment who say they have got sensitive skin (which is a sort to support her.47 of syndrome where people say their skin reacts easily to chemicals, it does not necessarily imply allergy), Q643 Chairman: Mrs Cox, do you want to and people with this sensitive skin have not reacted in comment? a very high proportion to the tested product and that Mrs Cox: Really I agree with everything I have heard. is what it really means when it says “dermatologist From my perspective, the National Eczema Society, tested”. I look at a lot of these preparations and what along with several other of the patient support is in them when it says “hypoallergenic” and I see a groups in dermatology also seek to fund medical whole list of things which I know can cause allergy, research. One of the challenges that we are finding, in so I am rather cynical about the label of addition to the obvious one that we too find it hard “hypoallergenic”. to raise funds, is that in fact it can be increasingly Y di cult to find appropriate projects and centres to Q646 Chairman: Mrs Cox? fund, so I think we have a chicken and an egg. Mrs Cox: My personal view is that both the term Chairman: Thank you. “hypoallergenic” and “dermatologically tested” for somebody who has an allergic skin disease are hugely Q644 Lord Colwyn: Do you think that the allergy misleading, and I can tell you from personal specialism is an unattractive career pathway for experience that you can put either on atopic skin and undergraduates, leading to postgraduate study? react massively. Dr Nasser: I think for undergraduates whenever I have taught allergy in Cambridge it has always been Q647 Chairman: My final question to you goes back very well received and with great interest. For to education—and I have to redeclare an interest postgraduates there are so few training positions that which I have already declared—at CardiV University it is diYcult to answer the question, but certainly where the distance learning course is educating over when we advertised for a trainee specialist registrar 400 GPs every year and those GPs are in the Royal we had lots of applicants, but there are so few College of General Practitioners’ Special Interest training positions available. I do not think it is Group, forming the GPSIs (GPs with a special necessarily an unattractive proposition but I think it interest) across the country. In five years there will be is important there are jobs they can go into once they more than a further 2,000 of these. Do you have any are trained. So that is the way to make it more comment as to how these GPs, whose education attractive. has been evaluated, are being received by the dermatology community, given that the Royal Q645 Chairman: I just want to finish up with two College of GPs has certainly embraced their questions which are quite unrelated. The first one development? relates to cosmetics where the label “hypoallergenic” Professor Gawkrodger: This is a major medical and is often attached to cosmetics, bed linen, all kinds of political question at the present time and one of the items. I just wonder if you have any comments about driving factors for it is the wish of the Department of what it actually means, and whether it is meaningful? Health to see more dermatology and other specialties Dr Nasser: I will start with that. I do not know delivered closer to the patient’s home. The actual anything about cosmetics but I understand that regulations for being a GP with a special interest are hypoallergenic simply means “less likely to cause an being defined at the moment by the Royal College of allergic reaction”. With that I will pass over to General Practitioners and other organisations and so colleagues. there will be certain criteria that these doctors will Professor Gawkrodger: I think it is meaningless need to fulfil to take on that role. As regards the view basically. There is no regulation of the term of the British Association of Dermatologists, we are “hypoallergenic”. What may have happened if it says not against the idea per se. I think we recognise “dermatologist tested” or something of that sort is that not all dermatology can be delivered by that in one of a small number of testing centres in the dermatologists, there just are not enough, so some UK a dermatologist in conjunction with a testing care has got to be delivered by GPs with a special organisation has actually patch-tested a number of interest. Most skin care at the moment, as you individuals with diVerent skin types, including people know, is done by general practitioners not by 47 The apparent lack of interest in research into urticaria is due to dermatologists. What we are concerned to ensure is many factors, including the diversity of presentation of the disease, the relatively small number of doctors with a special that the GPSIs are actually integrated into the local interest in it, the time pressures on clinical posts that prioritise schemes so they actually work with secondary care service work, training and clinical governance, the lengthy doctors and are not a separate organisation. As long approval process for research projects through ethics and research committees and the current lack of new treatments for as they are integrated with the secondary care so that urticaria under development by the pharmaceutical industry. people in secondary care know what they are doing, allergy: evidence 251
28 February 2007 Mrs Margaret Cox, Professor David Gawkrodger, Dr Clive Grattan and Dr Shuaib Nasser know their capabilities and they know what can be care in dermatology any further that is what they are oVered in a hospital environment, then that should bound to get because we will then go back to the safeguard the patient to receive good-quality care position where there is nobody to train people in because it is the quality of care that the patient gets the future. that is the key theme to this. The patient must not be disadvantaged by being seen by a GPSI compared to Q648 Chairman: Do you want to add anything, being seen by a consultant, and if the patient requires Dr Grattan? to be referred on to another specialist or to see a Dr Grattan: Little; I think it has been well said. I consultant dermatologist then they have got to have would just observe that distance learning courses will that available to them. So long as these safeguards produce a qualification and a certificate but that does are in place then the British Association of not necessarily translate into clinical care that has Dermatologists is happy to support the scheme. been supervised and audited, and that is the second Mrs Cox: A couple of points. The first is clearly I part of the education.48 welcome the fact that there are GPs who are receiving Chairman: Can I thank you for coming today. If there additional training in dermatology through the is additional information that you would like to give distance learning courses. However, I do have from a to us as a Committee, then please feel able to send patient’s perspective some concerns around the way that in. Your comments have been very helpful patient services are already being delivered in a lot of and you will be sent a transcript from today’s places across the country in that while there are of proceedings. Thank you. course some excellent GPSIs, as things currently stand, there are also people fulfilling that role with 48 The training and supervision of GP’s with a special interest in Dermatology in Secondary Care is a requirement for achieving very limited education or requirement for CPD. I and maintaining acceptable standards of practice. Whilst have yet to hear a patient say that they would prefer an expanded base of practitioners competent to deal with dermatology problems in the community should be in the to have a lower quality of care closer to their home. I interests of patients it is essential that Primary Care Trusts and think on balance what a patient would like to have is Practice Based Commissioners do not fund GPSI posts in an appropriate level of care. I am not at all convinced Dermatology and Independent Treatment Centres at the expense of Dermatology specialists in Secondary Care. These that that is currently what they are getting. I am posts should be expanded rather than reduced to meet the wide genuinely worried that if we destabilise secondary needs of patients with skin disease, including allergy. 252 allergy: evidence
WEDNESDAY 7 MARCH 2007
Present Colwyn, L Rea, L Finlay of Llandaff, B Selbourne, E of (Chairman) Simon, V Haskel, L Soulsby of Swaffham Prior, L May of Oxford, L Taverne, L Platt of Writtle, B
Memorandum by Professor Jonathan O’B Hourihane, Professor of Paediatrics and Child Health, University College Cork, Ireland Nearly half of the population are now vulnerable to developing allergic conditions, including food allergy. Allergic conditions are usually chronic and low intensity but have a significant impact on quality of life of both the patient and their families, whose lifestyle may often be very restricted. The prospects of unexpected allergic catastrophe or anaphylactic death are real issues for many families and should not be underestimated. Similarly the seasonality and short duration of high intensity symptoms may not be elicited by a casual medical enquiry. Many modalities of treatment that are still common are very outdated and put suVerers at significant risk of side eVects, when modern, safe treatments are more eVective but not widely available. Food allergy is widely thought of as merely an early step on the “Allergic March”, where eczema and food allergy merely precede rhinitis and asthma. This is to underestimate food allergy’s critical impact on health and quality of life of aVected children and its potential to cause fatalities, usually in older children and adolescents. However there are few or no known lifestyle factors that are uniquely associated with food allergy and it must be considered therefore in the context of known or suggested risks for allergic diseases. Biparental atopy is now common and appears to be a strong predictor of allergic disease in oVspring. Allergen avoidance while pregnant is not eVective. Being first born is linked with higher allergy rates. Housing conditions/location and parental occupation are also influential eg lower allergy rates in farming families in Germany. The role of mode of delivery (vaginal delivery or caesarean section) is controversial. Changing weaning practices and the impression that organic or exotic fresh food is better for children than traditional staple foods may be linked to the appearance of allergies to foods that would have appeared bizarre to previous generations.
Memorandum by Dr Mark Rosenthal, Consultant Respiratory Paediatrician, Royal Brompton Hospital There is an increasing demand from the public for allergy services. This has stemmed from partly a modest true increase which may be stabilising (Thorax, 2007; 62: 91–6), the comparatively recent recognition that certain infant symptoms may be manifestations of allergy, a greatly increased public awareness, and all fuelled by the rare but well publicised deaths from food allergy. This has been compounded by a large amount of lay literature much of which is non-evidence based. There is a large body of scientific data and clinical trials testifying to the value of, for example, desensitization for hayfever and venom allergy. However, there are a large number of “complementary” medicine services from the clinic to the high street advertising allergy testing services almost all of which are unproven; examples being hair testing and passing magnets over the body. These represent a danger to the public—for example, we have seen children lose weight as a result of completely unnecessary exclusion diets. There is also the danger which I have seen manifest in otherwise sensible consultant clinicians that almost any symptom in a child can have an allergic dimension placed on it. Allergy is following a well known pattern of medical inventions. Having been comparatively ignored in the past and under-diagnosed, under-researched and indeed under-funded, there is now tremendous (over)- enthusiasm, possible over diagnosis and a surge in interest and funding. In a few years the pendulum will swing back to an extent so that allergy takes its rightful important but not cuckoo like place in the spectrum of childhood disease. Disentangling the true facts from misinformation and hype is naturally problematic. Allergy suVers from a lack of detailed understanding; for example why do 95 per cent ! of milk (and egg) allergic children grow out of their allergy whilst only 15 per cent of peanut allergic children do so; and why do the overwhelming majority of children not have food allergy? Apart from tree/grass hayfever and bee/wasp venom allergy desensitisation, the rest can only be prevented and managed given the current state of medical knowledge. Does infant avoidance of risk foods especially peanuts reduce or increase food allergy later is the subject of a large study at its earliest stage. There is no formalised allergy training programme for doctors in the UK certainly in allergy: evidence 253
7 March 2007 paediatrics and perhaps it should have greater prominence. Is the tremendous increase in prescriptions for adrenaline injection devices (1/80 children in Manitoba, Canada carry one) serving children well and protecting them or merely leading to social diYculties and greater family anxiety. Out of countless prescriptions I have written over the last 12 years for such devices only one has ever been used. This committee has assuredly chosen a minefield to walk through.
Examination of Witnesses Witnesses: Professor John Harper, Professor of Paediatric Dermatology, Great Ormond Street Hospital, Professor Jonathan Hourihane, Professor of Paediatrics and Child Health, Cork University Hospital, Dr Warren Hyer, Consultant Paediatrician and Paediatric Gastroenterologist, Northwick Park and St Mark’s Hospital, and Dr Mark Rosenthal, Consultant Respiratory Paediatrician, Royal Brompton Hospital, examined.
Q649 Chairman: I am Lady Finlay, I am chairing problem of children. I do not know whether you want this Sub-Committee and this is our tenth public me to develop further, but the prevalence seems to be hearing in our inquiry into allergy. I would like to increasing which has been documented in a number welcome you as witnesses today and, also, members of studies. It is a worldwide problem with some of the public who have come for this session. There is countries having a much higher incidence of eczema a note declaring the interests of Members of the than others. Committee, so we will not be going through declaring Professor Hourihane: I am a paediatric allergist, so my our own interests during the session. We would like particular interest is in food allergy. There is data to to go through and ask you questions, and it would be show the prevalence of peanut allergy in the United helpful, because we have a lot of things we want to Kingdom has trebled since 1996 from 0.6 per cent to cover, if we can try to keep answers fairly tight so that 1.8 per cent, which is one in 55 children. Other food we can move on. I hope everyone will contribute to allergies are less common in older children but the the session. I wonder if I could start by asking you burden of allergic disease with food allergy is borne each just to introduce yourself and then I will go into by the pre-school child, and it may be that up to 6 or questioning. 8 per cent of pre-school children will have Professor Harper: I am Professor John Harper from experienced an allergic reaction to food by the time Great Ormond Street Hospital and the Institute of they go to school. There is attrition of this prevalence Child Health in London. to about 2 per cent in adults with food allergy, and I Professor Hourihane: I am Professor Jonathan think the other witnesses will talk about asthma. The Hourihane, from the University College, Cork in issue about food allergy being a minor problem Ireland. which then evolves into asthma appears, maybe, not Dr Rosenthal: Dr Mark Rosenthal from the Royal to be correct any more because the allergies that Brompton Hospital in Chelsea. children are having now are the ones that are known Dr Hyer: I am Dr Warren Hyer, from Northwick to persist into adulthood. So we may see a hardcore Park and St Mark’s Hospital in northwest London. of up to 3 per cent, I imagine, with serious allergies, like peanut and shellfish, etc. Q650 Chairman: Thank you. I wonder if you could Dr Rosenthal: I am a respiratory paediatrician and, start oV by telling us how the prevalence and clinical therefore, my slant is on asthma as well as food spectrum of allergic diseases diVers between adults allergy. Certainly asthma has increased quite a lot and children. over the last 50 or 60 years, but is probably Professor Harper: I am a paediatric dermatologist, so plateauing-oV as a recent study has suggested, or my take on this subject really relates mainly to atopic possibly even falling. I agree that the concept that dermatitis, or eczema, in association with allergy. asthma is allergic is far too simplistic as asthma Eczema is a major part of my work. The prevalence covers a very wide spectrum of conditions whose final in children ranges from 10 to 15 per cent, and there common pathway of symptoms are very similar. have been some studies approaching 20 per cent. So Therefore, it would be a mistake to say that asthma it is a very common problem. It is primarily a clinical was an allergic condition only. issue in childhood, particularly children under the Dr Hyer: Specifically to answer your question about age of five, but the predisposition to developing why it is diVerent to adults, I see this as a atopic dermatitis, or eczema, does not really go away. paediatrician who serves the population as well as a Something like 10 per cent of adults still get eczema paediatric gastroenterologist. The diVerence with my from time to time, and in a smaller percentage, maybe children compared to adults is children often suVer around one per cent, this is quite severe. So eczema many diVerent manifestations of atopy. So if they is right across the whole age range, and is primarily a have peanut allergy they may have very severe 254 allergy: evidence
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal eczema. If they have peanut allergy their asthma is a significant role in a significant proportion of children. greater risk for a life-threatening event. There are That has been validated by international data and much more multi-organ issues in childhood than that is not concurrent with what happens in adult there are in adults, where it may be that only one practice, so there must be a skew to greater allergic manifestation of atopy will persist. As a consequence, phenomena in children. the workload that has come forward to a simple Professor Hourihane: Part of your question was: is it district general hospital has been suVocating in its more diYcult to diagnose allergies in children. It is if volume of children with complex, multiple allergies, you have got nobody to make the diagnosis. who may just start with eczema, and it may be very Dr Rosenthal: I would say, from an asthma severe eczema, and persist with potentially very perspective, that allergy in the sense we are discussing serious restrictive multiple food allergies as they get it, is the cause of a relatively small proportion of older. I think this is a big diVerence and has been well- asthma in childhood. There are a lot more important documented in good quality, prospective studies environmental or other precipitants of asthma than looking at the natural history of these children with allergy. very complex multiple food allergies. Q652 Lord Haskel: Professor Harper said that some Q651 Chairman: Thank you very much. I wonder if countries have a higher prevalence of eczema than you could also explain something else to us. The others. Is there any pattern to this? Is it less developed conditions such as asthma, rhinitis and eczema can countries or more developed countries? have allergic and can have non-allergic etiological Professor Harper: There is data. I do not know how backgrounds. I wondered whether the balance of reproducible this data is but there are studies that allergy, and true allergy, that it plays in these show a lower incidence in developing countries conditions is diVerent in the childhood population to compared to more Westernised countries. Also, the adult, whether allergy is more diYcult to diagnose migrant populations; those coming from developing in the childhood population and whether the balance countries to the UK or the USA are more likely to of importance of allergy on life is greater or lesser in develop eczema. It is really complicated. It is not children than in adults. I do not know if you are able quite clear what these environmental factors are but to answer that. it does seem that Westernisation is relevant in some Professor Harper: In relation to eczema, I think that way. we need to recognise that a proportion of children Dr Hyer: We know that the prevalence of allergic V with eczema also are susceptible to allergy. You can diseases di ers even within developed countries, and certainly have children with eczema who do not have certain parts of Australia and certain parts of Europe allergy as a major problem but a proportion do, and carry a much higher prevalence, of which the UK this can be very diYcult. The data as to what (certainly from within the ISAAC study) does not percentage that is is variable depending upon which favour well; we have some of the highest prevalence age groups are looked at and how they define eczema. of allergic disorders than anywhere else in Europe. It is complex because we do not understand the Professor Hourihane may be able to validate that. relationship between eczema and allergy very well. In Professor Hourihane: What I would like to say is that those that do suVer with allergy as an issue, allergic in less Westernised parts of the world, such as reactions can be a major factor in making the eczema Western Africa, they can eat peanuts at the age of six worse. So you need to address that almost as a or eight months without ever developing peanut separate issue. This is a situation that is mainly seen allergy. So maybe it is related to the environment, the in children, and as they go into adult life several of nature of the food allergen and its timing of these common allergies, like cows’ milk, become introduction. Peanut is not the problem all the way better tolerated and only a few allergens persist as a around the world that we have the perception it significant problem in adult life, such as peanuts and, might be in the UK. maybe, kiwi fruit. Dr Hyer: In relation to food allergy, food allergy, as Q653 Lord Taverne: A recent article by the you have already heard, is principally an issue for International Study of Asthma and Allergies in pre-school children. So its relationship to eczema, for Childhood found there was a rise in the prevalence of example, will mean that allergens and food allergens allergy symptoms, particularly in the 6–7 year-old are more likely to be associated with that. We know age group. I find the picture rather confusing: I heard that children with severe eczema, for example, carry Professor Harper say that across the whole age range a 50 to 60 per cent chance of having significant food there is a prevalence of eczema increasing; from allergy. That data is not supported in adult practice. someone else that asthma was, perhaps, falling; there So if you take, for example, eczema, from my is more multi-organ allergies in children, and Dr perspective, you can see that food allergy has a Mark Rosenthal’s statement that we have here allergy: evidence 255
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal suggests that there has been a modest true increase Dr Rosenthal: I might slightly demur on that one in but it may be stabilising. Do you see an increase at the that there have been good studies from Germany, moment, particularly amongst children? If so, what is Switzerland and Austria showing the eVect of being the reason for it and what can be done about it? pregnant and attending to farm animals and whether Professor Hourihane: You may have heard from other the child after birth also got into the barn, and their witnesses in previous sittings about the hygiene risks of having asthma at the age of seven was hypothesis, which appears to be the most plausible or reduced almost to zero compared to other farmers most robust of the explanations. I think there is not whose wives, when pregnant, did not go into the barn much more to say. That is what we think is the or have contact with animals. So exposure in early life reason. It appears that allergic conditions are the certainly aVects something, though why does remain price that a small proportion of our population pay completely unanswered. So you can see from the for the way the entire population lives. various answers that this is a highly complex problem Dr Hyer: Just so it is not focused on the 6–7 year-old, of which we only know a very tiny amount. which is the outcome from the ISAAC study, there Dr Hyer: There will be more than just the hygiene are numerous studies (and there are at least seven hypothesis to account for this. People have looked at studies in the UK) which looked at the prevalence of diet, polyunsaturated fats, cereals, grains, the way allergy and which validate that it happens across food is prepared, breastfeeding practices, nutrition many age ranges, and not just limited to the 6–7 during breastfeeding. All of these—in fact, Gross which was reported in that specific study. That data National Product of your country can also predict can be looked at throughout the UK, it can be looked your risk of atopy. There are such complexities that at throughout Germany and many other parts of the hygiene hypothesis alone is a very valid hypothesis Europe. So I think it is important not just to assume but it is made so much more complicated than that. that there is a rise in one specific age group. Q655 Lord Taverne: It has already been mentioned, but I was going to ask, whether early viral or bacterial infections predisposed infants to the development of Q654 Lord Taverne: Are there signs of a plateau? allergies. Stabilisation? Dr Rosenthal: If you take studies of American day- Dr Hyer: There will be a bias for how data is care inmates, so to speak, they will have far more validated and the quality of the data collected viral illnesses and virus-associated-type wheezing because, of course, allergy is quite trendy and people episodes, which currently are not defined as asthma may over-report. From a clinical perspective, I have but their risks of having asthma at the age of 11 is had to change my practice in a district general reduced as a result. So this can be argued in many hospital because I can no longer practise paediatric directions, but the studies from the southern states of gastroenterology without tackling allergy. This was America are quite compelling in that regard. not the same issue 14 or 15 years ago when I started Professor Hourihane: There is similar data from my training. The prevalence of peanut allergy is such Scandinavia about early entry to day-care, which is that it has now reached, as we heard, around about 1 part of the social contract in those countries where in 55. The allergy to agents such as tree-nuts and to mothers go back to work and children go into state- fruits and pollens did not exist in my practice 20 years run day-care. The children who go into state-run day- ago. I have kept my eyes open during that time, and care before six months, compared to those who go in I do not know whether it has plateau-ed but I have after a year or 24 months, have lower rates of asthma certainly seen it rise. and other allergic conditions. So it is guilt by Professor Harper: We can make these clinical association. It is very hard to prove that any observations and you can ask why, but there are particular—I do not know how we would prove— many unanswered questions. We really do not know viral infection in infancy prevented allergy. However, the answer. It is interesting that Professor Hourihane there are data regarding children who have either mentioned the “hygiene hypothesis”, and that been vaccinated against measles or had wild measles, actually is all it is, a hypothesis; that is, cleanliness in Guinea Bissau, and those who were vaccinated— and the lack of exposure to viruses and bacteria may i.e. they did not have the wild-type infection—had make you more susceptible. However, the opposite is higher rates of allergies than those who had had not true; if you actually have children who are measles and survived it. So it is a trade-oV between exposed to infection there is no evidence whatsoever surviving measles or not. that this reduces your risk of allergy or atopic dermatitis. In fact, there are many papers on Q656 Viscount Simon: The “allergic march”/ infection in early life triggering eczema and asthma. progression (whatever you like to call it) describes the So it is a hypothesis. march from mild allergies, such as rhinitis, to more 256 allergy: evidence
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal severe conditions. Is there any particular age at which and eczema are there in infancy and rhinitis is what children typically are most likely to develop these develops after several years of exposure to allergens. more serious disorders, and is there anything that can The perception that the diseases become more severe be done? is because the burden of death due to allergies is in Dr Hyer: It depends what you mean by “more adolescents and teenagers, whose approach or serious”. I would say that multiple food allergy in a response to their illness puts them at risk; they ignore child under one or severe eczema which impacts on the warnings, they take risks, or they eat in places your growth in a child under one is, perhaps, more where they may not be sure of the provenance or serious than asthma that is looked after by Mark that safety of the food. So the severe illnesses start in is older. I would fight that corner. People progress childhood and persist, but the responses of through diVerent manifestations of the allergic individuals to the conditions may alter their risk march at diVerent rates. For me, the burden of through life, as for any other condition that an workload is the preschool child who has multiple adolescent may have to suVer. food allergy, but as I continue my clinic as they get older many of them became tolerant to the most significant foods, which are milk and egg; they may remain allergic for life to foods such as peanut, which Q657 Viscount Simon: It is a common belief that may amount to a serious risk, and then as I continue most children grow out of asthma and allergy, but am running my clinic I inevitably end up running an I right in thinking that this may not be true asthma clinic or a rhinitis clinic as they get older. particularly with regard to food allergies? People do progress through symptoms. The Dr Hyer: There are food allergies that persist. The preschool child may lose their original food allergy, simple ones that resolve, like cows’ milk and the egg, but I am not clear that I have a specific age where the not all but many children will outgrow. Those with threat is greater. I consider the preschool child at multiple food allergies sometimes do not and there is significant risk. a significant burden of children who have multiple Professor Harper: I would like to make an important food allergies who are not outgrowing them. That comment. I do not like the term “allergic march”, means that there is a cohort coming through to personally. I know it is used in the literature a lot but adulthood, potentially, who have a one-in-50 chance it is often misused; it is a very loose term and people of having a severe adverse event were they to face understand it in diVerent ways. It seems to me to peanut. So in answer to your question, some of assume that there is a progression: that you develop the food allergies you do not outgrow. There is eczema, then you develop your hay fever and then information still to be gathered—remember, we are you develop your rhinitis. I think, these are all seeing a rise in the prevalence of peanut allergy—but individual diseases which are associated and, at the moment these ones seem to persist. perhaps, aggravated by allergy, and that they vary Professor Hourihane: I have been told twice within a from one child to another. There is a time diVerence; month by two families that they wish their child had the onset of eczema is primarily in early infancy, cancer instead of food allergy because there is a cure under one, and then perhaps the peak of asthma for cancer. onset is a bit later and then the onset of rhinitis after that. However, it is time-related rather than necessarily a progression in an individual. The ultimate point here is: is it progressing in such a way Q658 Chairman: You commented earlier on about that it becomes more severe? I am not sure that is the absence of the ability possibly to diagnose true. There are genetic factors as to why some accurately. How much do you see that as a problem children are born with severe eczema and asthma and amongst children and then, moving on into rhinitis, but it is not a progression from one of these adulthood, that the actual allergic nature of their disease entities to another. disease has not been adequately diagnosed? Dr Rosenthal: There is a danger of moving from the Professor Harper: It is also a perception by many particular to the general. There is a very good study doctors in diVerent specialities, because this range of from Cambridge which looked at food allergy events conditions can present to a whole number of diVerent and looked at the risk of progression to a more specialities and they each have diVerent protocols of severe event subsequently, admittedly following management. It all needs to be much more co- intervention by training and advice, etc. Certainly in ordinated, with a greater awareness for potentially children the risk of progressing to a more severe event aggravating factors, whether it is eczema or asthma was virtually zero. and so on, and to investigate allergy. That is what is Professor Hourihane: However, it is not the case that important, and to be able to have the facilities to be they move from a benign condition of eczema to a able to do that. There is a need for awareness right up more severe condition of food allergy. Food allergy from general practice to specialist. allergy: evidence 257
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal
Q659 Lord Colwyn: Would children stand a greater children of nine or 10 who are still on elimination chance of outgrowing an allergy if they were on a diets for a reaction that they had in the first year of totally restrictive diet which prevented any taking-in life. Their social wherewithal is very limited. of that food? Or would they stand more chance of outgrowing it if they carried on eating it and slowly Q660 Lord Colwyn: It is a sort of do-it-yourself acclimatised themselves to it? immunotherapy? Dr Hyer: A wonderful question and there will be Professor Hourihane: We would not advise that. There many diVerent answers to that. We know that in is the risk of an extreme allergic reaction which may terms of primary prevention the best tool is to breast be augmented by a period of elimination. That has feed. Breast feeding is not a mechanism by which you been well-described in the dermatology literature, are not exposed to allergens; you are exposed to particularly by Tim David from Manchester. So hundreds—thousands. The advice of the Department avoidance and then casual reintroduction has caused of Health, for example—and this is particularly problems. controversial and will cause much concern—about Dr Hyer: This is, surely, eVectively, an argument that not having peanuts to eat in the first three years of life these children (and the numbers are not small; we are if you are at risk may not be what happens in the rest talking about 2 per cent of all children have cows’ of the world. So when you compare that with data in milk protein allergy of some form) need to be seen in Israel where the prevalence of peanut allergy is so services outside primary care with access within a few low, is it because they are weaned on to sweets and weeks of the diagnosis. Some of these children are crisps that contain peanut? We do not really know three months and they cannot wait 12 weeks on a the answer to that, and this is being addressed by waiting list; they may have failure to thrive; they studies which are funded studies at the moment. We may be breastfed and the mother does not know know that breast feeding helps. We know that if you what other foods to give this child; they are told to have severe eczema you may benefit by going on to a over-restrict unnecessarily and you can see that hypoallergenic feed when weaned and not being fed this ultimately impacts on these children, not cow’s milk formula, but because of the diagnostic infrequently they will end up on the ward; they will be diYculties that you so kindly mention, selecting admitted because they just could not get into a which patient should take on which avoidance service. Perhaps this is an opportunity to think about pattern is very complicated and sometimes managed the access of this group of children who, ultimately, in general practice but really ought to be managed at will represent an allergic burden for many more a specialist level, whether it be at an allergist level or years, because they do need specialist care. It is not an organic-specific consultant who can take on that just about whipping out a few foods and doing-it- question. It is very complicated and very individual yourself at home. because the diagnostic test diYculties that you have alluded to requires judgment which is not available in Q661 Lord May of Oxford: We have actually general practice. covered much of the ground of the question I was Professor Hourihane: I would rarely put children on going to ask, which would have been: against the total elimination diets. I would say it happens, background of a lack of understanding of what is maybe, once every year to eighteen months. There are actually happening and causing the rise, what, if any, other ways. The major allergic manifestation is consistent advice is or should be oVered to pregnant usually eczema under the age of one and failure women and mothers of young children regarding to thrive with gastro-intestinal symptoms. So an allergy prevention? Is there any consistent advice that integrated approach and the holistic management is recommended that be given? If so, what do you of these things is the key. Elimination can be think of it and do you think it is well-founded? appropriate but it is extremely limiting on the family; Dr Rosenthal: The Cochrane database on this aspect it makes the child unadventurous in new situations, of prevention or food avoidance in pregnancy or socially isolated and it should not be undertaken lactation has been revised more often than any other except under specialist care. So we are not in favour Cochrane database, and the conclusion remains of such elimination diets being started in primary entirely the same; that there is no evidence— care before being assessed by an allergist, because, for definitely no evidence—in terms of food avoidance one thing, they may be nutritionally unsound unless during pregnancy, and during lactation possibly. they are properly supervised and they may be Therefore, is it scientifically well-founded? It is promoted or persisted with for far too long after the scientifically well-founded only to the extent that allergy has gone away. As we have heard, milk and nobody still has any idea. egg allergy go away in the first four or five years of Professor Hourihane: Could I read out what the life. I am encountering now, in Ireland, where there is current European Academy of Allergy and Clinical an even less developed allergy service than in the UK, Immunology guidelines for this are? “The dietary 258 allergy: evidence
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal recommendations based on present knowledge: all Dr Hyer: No. infants, no special diet during pregnancy or for the lactating mother; exclusive breastfeeding preferably Q664 Lord May of Oxford: Do you not think they for six months, on the basis of WHO advice, but should be? at least four months. If supplement is needed Professor Hourihane: Clearly. conventional cows’ milk formula is recommended.” So there are no particular dietary restrictions for the Q665 Lord May of Oxford: That is not postgraduate general population. “Avoidance of solid foods education, that is just basic practice. preferably until six months but at least four months.” Professor Hourihane: I would declare an interest: my Further recommendations for infants who are at high wife is a GP and if you went into any GP’s surgery the risk of allergic disease (so they would have a father, list of guidelines on their desk is taller than their mother or sibling with allergies) are that if computer. It is an impossible position to be put in. supplement is needed extensively hydrolysed formula We need to be able to deliver targeted specific advice is recommended until four months, and after the age or accessibility in a way that is accessible for them, at of four months high-risk children can be nourished a time when they need it as opposed to when they are like non-high-risk children. The important point is meant to be doing their reading. They need to have it there is no particular advice for pregnant mothers. immediately available in some way that they can—I Professor Harper: This is a really important question do not know—Google it, for another word, on their that one is always asked. I see a child with eczema and desk, or Prodigy, or the other systems that GPs have allergy and the mother is wanting further children for information: “what do I need to do with a child saying: “What can I do? What should I do?” The with eczema?” policy we adopt is that just described by Professor Dr Hyer: We are all vaguely missing the point. A very Hourihane. As I said before, these children are seen significant proportion of these parents will not be by such a variety of diVerent specialists—it could be seeking advice from the medical profession, and they gastroenterology, it could be general practice, it may be seeking advice from complementary care could be a paediatrician, dermatologist or allergist, which may not be following these guidelines. The and so on—and advice does vary. It seems to me that paediatric gastroenterologist will follow those particularly among gastroenterologists there are recommendations. These are well-established doctors who maintain that mothers should be on a recommendations that have also come out of diet, but there is very little evidence to support this working parties that have worked with the World approach. If you look at published papers there are Allergy Organisation. It is good, solid advice but it is some papers that say it is good and there are some not current advice if you are one of the 25 or 30 per papers that say it is not helpful. At the moment, there cent of mothers who will take their small child with is no evidence that mothers should go on a diet at all. eczema to a homeopath, a complementary physician of some kind, who will, not uncommonly, over- restrict a child’s diet. We should not kid ourselves; actually, primary care is only one route that you Q662 Lord May of Oxford: In the first instance, that access advice on what to do with your child’s people are more likely to see their GP than a incurable skin condition. There are a not insignificant specialist, who may well have particular views of a number of children in my care who have significant good or, alternatively, peculiar kind, to what extent failure to thrive or social impairment because of do you think GPs are well-informed about this? restrictions imposed by non-medical resources. Professor Harper: I think this is crucial to everything here: and that is better education at primary level. Q666 Lord May of Oxford: This opens the door to a You cannot send every child with a potential allergy much larger question, which is the extent to which to a specialist—that is just not on—but what you can non-evidence-based medicine should be being do is give better education all the way through the purveyed within the NHS. medical system from whence they first go to a doctor. Dr Rosenthal: We would all have to go home now! Professor Hourihane: Only 4 per cent of primary care doctors who answered a survey by the British Society V of Allergy and Clinical Immunology reported that Q667 Lord Soulsby of Swa ham Prior: We have they had had any specific postgraduate education been talking about breastfeeding. Is there any transfer of either sensitivity or tolerance actively or about allergies. It is a blank page, I am afraid. via lymphoid cells in colostrum, for example? Professor Hourihane: It is certainly true that any allergen that a mother ingests—whether it is a food Q663 Lord May of Oxford: I guess what I am asking allergen or anything else—will be found in breast is, are they familiar with the guidelines? milk shortly afterwards. You can find peanut allergen allergy: evidence 259
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal in breast milk within 20 minutes of a mother eating it, there needs to be specialist allergy services which are and the variability of that goes from within 20 recognised nationally, and not just a few units stuck minutes to up to eight hours later. So it is not often in the south-east of England with nothing west of the case that you can say if it is not there in the first Bristol. Access to colleagues is a way round your hour it will not have happened. 0.5 per cent of suggestion, number one, and a realisation that allergy breastfed infants have cows’ milk allergy even though does have a role, not in all, but in some children with they have not been exposed to cows’ milk and that is complex profound atopic disease. due to intact milk allergens expressed in breast milk. We are talking about the tail end of a curve here Q669 Lord Rea: As a former General Practitioner I because all children are exposed to those allergens would like to put the view that most postgraduate that a mother expresses but we are talking about the education and keeping up-to-date received by GPs vulnerable, high-risk child who then develops comes from exchanges with the specialists to whom symptoms on the basis of that. they refer their patients. Certainly it was the case with mine; a good relationship with a local consultant and Q668 Earl of Selbourne: I want to come back to Lord good letters back from the consultant, with non- May’s question about the help that GPs might get patronising, postgraduate education included in the from this Committee in its report and the structure. text, is a very good way of doing it. However, the We come back, time and time again, to the cases, as problem is that there just are not enough allergy you have already reminded us, where it is impractical specialists for GPs to refer their many patients that to suggest that children, in the main, can see a they might like to. specialist; it will be the GP who is expected to be able Professor Hourihane: We will need to grow some to deliver advice and diagnosis. We have also been allergists to populate the regions where there are not told, time and time again, that there is very little any, and we cannot do that until we have proper postgraduate training, and absolutely nothing at centres of research and training for allergy itself. The undergraduate level—we have been told this is 20 NHS responds very well to standards and the minutes, or so. What I would really like to hear from Australia College of Allergy (I forget its particular you is what precisely you would like us to say which acronym) has developed standards for management needs to be put into the hands of a GP which would of anaphylaxis in the community which are very V allow him or her to be more eVective in the diagnosis accessible. O the top of my head, one of them is that and treatment of allergies in children. no person should have more than one episode of Professor Harper: In simple terms they need to have untreated anaphylaxis during their lifetime. That is formalised basic training in allergy and to make sure quite a simple thing; it should happen once and then that there is good communication with their local you should have enough training and support so that allergy specialist, and all the other specialists that it never happens again. All children who have had relate to this group of disorders. There should be anaphylaxis should be seen within one month. Those protocols of management and that guidelines are are accessible, understandable, achievable targets if agreed nationally. In the past, allergy, at all levels, we put the resources where they should be. has not been taken seriously enough. There is now a Chairman: I think that takes us very neatly on to lot of background science to allergy and a lot of Lady Platt’s question. formulated ways of managing these children. I think that GPs should have CPD training specifically for Q670 Baroness Platt of Writtle: What are the allergy, if they have not already had it. priorities for research with regard to the primary Dr Hyer: This has been looked at by the Royal prevention of childhood allergy, and who is carrying College of Physicians. They produced a report, which it out in this field at present? I am sure you are aware of, about three years ago. Professor Harper: Perhaps I could start. There is There is an issue that it is not taken seriously by minimal research in eczema. It is an area that I have general practice and one of the big pitfalls as a child a particular interest in. We have a research team at with eczema is that the GP may say: “Look, it is just Great Ormond Street, but there are very few other not related to food” and they carry a 50 per cent places that are doing proper basic science skin chance of being wrong, because we know the biology research on eczema and why this condition relationship between food and eczema, potentially. makes children susceptible to allergy. We need to This then produces a further barrier between the know more about the basic biology of what is patient and the GP. There needs to be a realisation happening to children who get inflamed skin with that it has to be taken seriously; these are real eczema, and why—address the question—are they diseases, they are not made up by homeopaths; they more susceptible to allergy, because a lot of the are real disorders. GPs, therefore, need to have a allergy is actually through the skin. I just want to resource that they can access for advice. That means make one point because I know all these facts are 260 allergy: evidence
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal being recorded, and it is wrong of me to disagree with thing can be disentangled then primary prevention is my colleagues, but it does highlight the lack of not actually possible because avoidance does not research and the lack of good knowledge. Food seem to work. Saturation in certain cultures appears allergy is important but there is a wide spectrum of to work and why is it diVerent? That is where the allergy, not just foods, but inhalant allergens and research should focus. environmental allergens. Food allergy is not 50 per Dr Hyer: In answer to “Where should it be done”, it cent of children with severe eczema; it is probably should be done in established departments of allergy more like 10 per cent. Nevertheless, it is an in university departments who can manage sensible, appreciable number that must not be overlooked. If prospective studies, and it should not be done by we understood more about why children with eczema small, little observational studies done in little parts get allergy, maybe we can address that, but there is a of the country. There needs to be a clear idea about lot of research that is needed focused on atopic how we are going to look at primary prevention dermatitis. because we do not really know where to target, as you have already heard. That probably should be left to university departments or specific tertiary allergists Q671 Chairman: We, particularly, too, want to look to work with primary care and work out which at primary prevention rather than research into studies will answer where primary prevention works. established disease. You are talking about prevention in children with eczema. I wonder if others of you have comments on that. Q672 Earl of Selbourne: Could you tell us how the V Professor Hourihane: In high-risk groups, defined as typical treatments di er between adults and children having a sibling or a parent with allergies, for conditions such as asthma, rhinitis, eczema and intervention, such as the delayed introduction of food allergies? solids, appears to be eVective. On a population basis Dr Rosenthal: I do not think they do. V it is very diYcult to see if that advice will be eVective Professor Harper: There is not a lot of di erence, in because intensive investigations in isolated terms of managing eczema, between a child and an populations are not eVective, so bombing their adult, except to respect the paediatric aspects; that in bedrooms and making their rooms hypoallergenic a child the surface area of the skin has a higher and very austere do not work for house dust-mite proportion to weight than in an adult and therefore sensitisation—removal of pets, etc. On a population absorption through the skin is relevant. We are very basis it is very hard to know what is the primary thing aware that what we put on the skin might be we need to know, but interventions regarding early or absorbed into the blood, but the principles of delayed weaning and selective weaning with low-risk treatment are very similar, both for children and allergenic foods is probably more of a plausible way adults, and most children can have their eczema in the first year of life with primary prevention. On treated adequately with topical therapy. the role of breastfeeding, I think, we need to maintain the excellent breastfeeding rates in this country and Q673 Earl of Selbourne: Are there some medicines try to get them up to the levels they have in which you have to be more careful with than you Scandinavia, where they have support groups for would with adults, such as anti-allergic medicines, women who cannot breastfeed, whereas in Cork we antihistamines and corticosteroids? have support groups for women who try to Professor Hourihane: If they are used appropriately. breastfeed. So we need to switch this round to make We use them down to very young ages, and Professor this a breastfeeding culture. Harper would do the same. Appropriately managed Dr Rosenthal: The question I always ask myself is they are very useful. One of the things I would like to why do most people not have allergy? How do they get on record is the fact that we should not be using learn immunologically to tolerate antigens and first generation antihistamines in children just foreign proteins that are presented to them? What because they are sedative to decrease their itch; we distinguishes 98 per cent of the population from 2 per should be treating the itch and then they will be able cent of the population, because until you know why to sleep. We should be using modern medications at that happens you cannot prevent it in the 2 per cent appropriate doses with appropriate frequencies, and of the population. On the studies from Israel, as Dr that goes for corticosteroids, immunomodulatory Hyer has said, why does everybody in Israel stuV therapies, such as tacrolimus and pimecrolimus, as peanuts down their throats, from birth virtually, and well as anti-asthma medications. never have a problem, and yet we in the UK have a Dr Hyer: I would argue that the treatment is diVerent comparatively large problem? Bear in mind that the in children for food allergy because it does not exist eating of peanuts has become much more common in in adults. I work in an adult hospital, which is a big the last 40 or 50 years with a rise in allergen, but in gastrointestinal service in North London called St Israel it seems to have no eVect. So until that sort of Marks. They do not need any food allergy services. allergy: evidence 261
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal
So the treatment is diVerent. You need specific food that peanut represents. I want Johnny to go to the allergy services for children which you will not need lunch rather than not go to the lunch. If he has to in adults. Why is it necessary? Because you need a bring a bag of equipment that he does not need to use multidisciplinary approach with dieticians; you do that is a diVerent matter; that can be left outside. We not have over-restricted diets; you want reliable ways want these children socialising normally with the of investigating children and interpreting the results extra caution that comes with an appropriate correctly and not with prejudice, and that is a adrenaline kit. We do not want them to ever have to diVerent treatment package to that which you get use it but we want them to have it available if they from adult practice. This requires dedicated services. ever have to use it. Dr Hyer: You have heard two diVering opinions. As a practising paediatrician this is a real challenge. I Q674 Earl of Selbourne: Can I ask Dr Rosenthal: he could give an adrenalin pen to every child who comes has given us an interesting paper and near the end in with a food allergy that might pose a life- of it he refers to the tremendous increase in threatening episode. It is not just peanuts; it is tree- prescriptions for adrenalin-injection devices— nuts, and it is potentially milk in smaller children. EpiPen, and the like. You hint that perhaps they are Every day I get three or four ‘phone calls from a being over-prescribed. Is there a danger in this? You parent and it is perhaps one of the commonest ask the question (and you do not actually answer it) that there might be an issue as to whether they are questions that is raised. There are guidelines out leading to social diYculties and greater family there; there are Australian guidelines, there are anxiety. Would you like to answer your own question American guidelines, but actually what to do in this on that? country is still not clear. It is a real shame for this Dr Rosenthal: The answer covers all the subjects from honourable Committee not to have clear guidance defensive medicine through to clinical practice. There from the four of us, because we do not know yet is no doubt that over the last 10 to 15 years the exactly who should carry them. This therefore prescription of these devices has rocketed, although I becomes an individual decision with a patient which actually say I do not know how many I have cannot be made, probably, in primary care safely. prescribed but only one has ever actually been used. These patients deserve to sit down and have a sensible Whether I am just lucky, I do not know. In quite a lot diagnostic process taking place where they find out of it there is a cost in the sense of social cost: Johnny which nuts they can and cannot have, see a dietician, goes to party, but Johnny has to bring EpiPen, have an emergency protocol and then, if they still feel antihistamines and all the rest of it. It may, of course, it is necessary, receive the adrenalin pens. This was a truly be necessary but it is not a free lunch in that practice that was put into place by the McEwan respect, and one has to be careful that the group and other colleagues who have looked at management of the condition is not worse than the packages of care. That cannot happen in general problem and only equals the problem. There has practice. So, in answer to your question, we need to been, though we still wait with baited breath, no have a relationship with our GPs, so that if they court case of which I am aware of the non- ‘phone us and say: “I do not know whether this prescription of such a device leading to not mother needs an adrenalin pen”, this is a decision preventing some tragedy and being sued as a result. that may last for five or 10 years, or a lifetime. Surely, So in terms of the criteria for when you should these patients deserve a consultation with either prescribe them, there is very little laid down and someone like Mark or myself or anyone who has the everybody has their views—they are much more specific interest and skills to make that decision with rigorous in America than, for example, here. As I put a parent. My plea to you is that it is not just leaving it in the statistics, one in 80 children in Canada carries for general practice to do. This is a question that was an adrenalin device, which is extraordinary. raised before. If you have a child you are weaning and Professor Hourihane: I am afraid I do not find it you are breastfeeding, with severe eczema, even if extraordinary at all when the prevalence of peanut general practice can manage it, perhaps it is wrong to allergy is even higher than that. In almost every one expect them to do so. We have the expertise, we can of the consensus documents about who should carry help at least on one consultation and share that adrenalin, if you have peanut allergy you should burden with the GP. The same argument happens carry one. So, if we do the maths on this, one in 55 with adrenalin pens. There are diVering opinions; children has peanut allergy but only (from Australia there is no fixed protocol a GP can follow; the in 2004) one in 500 children had an EpiPen. So to practice must change from one patient to another. It even increase the number of EpiPens just to provide is unfair to leave that specifically unsupported in for the single condition that is peanut allergy we general practice to do, and we should seek the people would need to increase the number of Epipens by a who have an expertise, whether it be a respiratory factor of more than six, just to cover the single allergy doctor or an allergist, to work out who should have 262 allergy: evidence
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal those pens before the whole population walks round resuscitative centres. I wonder if you have any with them. comment on that discrepancy between the German therapeutic practice, where they are reporting quite a Q675 Lord May of Oxford: Is the procedure that you major benefit? recommend that which is followed in Australia or Dr Rosenthal: In relation to my customers, so to not? speak, I have to wait a long time before somebody Dr Hyer: I have just come back from a sabbatical comes up who qualifies, at least in my view, but working in the allergy services at Melbourne maybe I am being too austere about this. If I was Children’s Hospital, which is probably one of the going to be cynical about the American viewpoint, it best established services around the world. There is is a very lucrative pastime. not absolute clear consensus. There is rapid oVering Professor Hourihane: I do not think that pertains in of adrenalin pens because they meet the criteria of the UK because of the structure of the health service. distance and inability to access hospitals as they may, The NHS is the laughing stock of Europe for its for example, in Ireland, but they certainly would not absence of immunotherapy for allergic diseases— if they were living within Chelsea. These are very briefly. The regulators are stuck in a 1986 mindset individual decisions, but the primary care is not the and need to get over that, and move with the science. same in Australia as it is in this country. Access to Professor Kay’s group and others have driven this to hospital specialists is not the same, and the need for areas which show that it is safe, eVective and its adrenalin pens is diVerent for whether you live in a impact is comparable to simpler medication, which is suburb round the corner to the Royal Children’s much more expensive. The issue for children, my Hospital in Melbourne or whether you live in Lord, is: is there some way that immunotherapy can Wogga-wogga in the outback. These people make prevent (the favourite term) “the march” or not? It individual decisions and we must make individual appears that mono-sensitised children who are patient decisions in this country, based not in allergic to just one allergen, if they are treated with primary care, about who should be carrying immunotherapy for that allergen, do not have the adrenalin pens. promotion or diversification into other allergies. So it appears that children may be the key group in which Q676 Lord Soulsby of SwaVham Prior: Can we turn we should be doing this. to immunotherapy? Is immunotherapy widely practised in this country? Is it as eVective in children Q678 Lord Soulsby of SwaVham Prior: It is an as in adults? A rider to that is, is there danger in using interesting comment that progress stopped in 1986. immunotherapy in children? Maybe we should take that on board. At what age Dr Rosenthal: Immunotherapy was used but fell out could you start immunotherapy in childhood? of favour in the 1980s, and Steve Durham did some Professor Hourihane: It is a very daunting prospect to very wonderful pioneering work in adults in tree and give children injections once a month for a disease grass pollen desensitisation in adults, showing an that they do not know anything about and you are immunomodulatory benefit which was continued trying to prevent a condition. Oral immunotherapy after stopping the therapy. It certainly does work in maybe the way forward for this, and I think everyone children and is used, though of course the entry would understand that nearly everybody, including criteria that you must not have asthma precludes food-allergic individuals, are tolerant of nearly quite a lot of them. Also, it is quite an onerous everything that they eat. So it is the tolero-genic injection regime, so getting a younger child to have it route, and it may be that we should be exploring that is very unlikely. People, therefore, have to be on a population base for sensitised children who, positively begging me before we undertake it. I am, down to the age of one or two, will be able to do that, personally, still very chary about it because most of although it has not really taken oV for children less the time non-immunotherapy treatments for this sort than five yet. of thing are eVective, and it is only the hardcore minority which you need to progress to that stage. Q679 Chairman: Do you have any comments from the food allergy point of view? Q677 Chairman: Our Sub-Committee visited Dr Hyer: From a food allergy perspective and from a Germany and there we saw immunotherapy being practising clinician, I am frustrated that I do not have used to a much greater extent than in this country, the access to immunotherapy that I would like to try with a much lower instance of risk than the old and see if I can reduce the burden of atopic disease, experience from this country, which was out in although nor am I also convinced yet about its primary care, which is where the problems were therapeutic benefit. That needs to be taken on and arising when patients were given these injections in introduced to see whether it works within this primary care, a long way away from any kind of country. There is one wonderful immunotherapeutic allergy: evidence 263
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal agent which is under-utilised in this country, which is you cannot really do it unless you have had some called breastfeeding. The Select Committee also need allergy training, such is the burden of clinical work to remember that if postnatal care was improved in that will come to you from food allergy. The training this country and the prevalence of breastfeeding programme for juniors needs to be modified to take rose we would already have our own biological into account that there is a specialty of allergy and immunotherapy, at least for some foods, that may that it will impact on their clinical practice and they oVer significant benefit. I do not know if that is a fair need to be trained in it. That is going to require comment. training centres—proper tertiary units with specialist supervisors in paediatric allergy and specialists who Q680 Chairman: Is there an onus then on midwives can train you in respiratory complications such as and health visitors to understand allergy better? asthma—and those need to be in place. Professor Hourihane: They are very powerful intermediaries of medical advice. The advice the Q682 Lord Colwyn: Does the Certificate of Government gave about peanut avoidance was much Completion of Specialist Training in Allergy involve more commonly adhered to if it was received from a paediatric training as well as adult allergy training? midwife than from a family care doctor or an Professor Hourihane: No, I think I was the first allergist, if you happen to have seen one. So they are paediatric allergist to go through the CCST scheme very important people. They also have got to stop the and I have got a CCST in general paediatrics and habit of giving individual bottles of milk to children immunology because allergy was not a recognised just to keep them quiet while the mother rests on her specialty at the time in paediatrics, and it remains so. first night, lying in. There are a key target population for training. Q683 Lord Colwyn: How do paediatric allergists work with adult allergists and organ specialists to Q681 Lord Colwyn: We have covered some aspects ensure long-term care for patients as they grow older? of training already this morning, and it has become Professor Hourihane: Paediatricians are very good at clear there is not a lot of postgraduate training organising transitional care. It is well-established for available, although I think in previous evidence we cystic fibrosis and asthma and other chronic did hear that it has been suggested that in group respiratory conditions. There has not been the practices specific doctors might be allocated the job evolution of paediatric allergy clinics on a broad of being particularly interested in allergy. Literally, enough scale to say that there is a logical and all my own training in medicine and later in dentistry well-defined structure of transitional services. In consisted of was training in how to deal with allergic Southampton, we transferred patients to the adult reactions to substances that we had introduced into services with an overlap of appointments. We did not the patients at the time. Can you tell us what training share clinics but we co-ordinated appointments. It is programme there is for paediatric allergists and is it a real risk that the children who have been carefully an attractive career path for a doctor? supervised with food allergies will then become the Dr Hyer: In answer to the last bit, if you look at the adolescents who leave all their kit at home and go to recent applicants by paediatricians for clinical restaurants at risk, so care of adolescents with training programmes and specialists in areas of significant allergies as well as significant asthma or speciality for the year three registrars, (in other words cystic fibrosis could be better co-ordinated. they have got about three more years to go) allergy is Dr Hyer: When I finish with my patients at 15 I do not one of the most popular specialties to go into. It is have anywhere to send them. I know who my now a credible paediatric resource and so it is paediatric allergy colleagues are, but I do not really popular. For the training I would have to refer to have access to strong adult allergy services. The Professor Hourihane. numbers are small because, as we have said, food Professor Hourihane: We need to have centres that allergy is principally a phenomenon of the pre-school can do the training where they can give the child, so it mainly fits within the remit of paediatrics, whole experienced complement of dermatology, but I do get 16-year-olds turning up to my clinic who gastroenterology, asthma and immunotherapy. It have oral allergy problems with pollen et cetera who has always got to be in centres where this can be done want to know where to go because I cannot see them and then these people need to be diVused out into any more, and I do not think I have anywhere to send other regions following training where they would them yet. then be able to interact with primary care. It needs to be in a place where everything can be done. Dr Hyer: Whilst you are being trained in your allergy Q684 Lord Colwyn: So are there particular I think it is true to say that if you take on other diYculties for specialised paediatric allergy services specialties, particularly paediatric gastroenterology, in district general hospitals? 264 allergy: evidence
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Professor Hourihane: They do not exist in district need to ask Dr Rosenthal his opinion on how long he general hospitals. has had to do it as a respiratory doctor, but I think it Dr Hyer: What happens in district general hospitals has taken me several years of clinical practice and is what is happening here. I am an organ-specific close liaison with my colleagues who are allergists specialist, I deal with the gut, and invariably I have to within London to get a feel for what I am doing. Just deal with food allergy. I got myself trained. I trained as GPs get back a reply from a consultant, I get myself in Australia in order to get the training that I responses back from my colleagues and so I know really needed, and I do not mean that in a derogatory how to step forward. I have many shared patients fashion and I am sure my colleagues would with for example Professor Harper so I have learnt understand that. I had to do that because of the how to address some of his practices as well. It has demand for services and the referral patterns. I think taken me a long time. If you put it in a training that probably answers the question. In a district programme the minimum you would need, for general hospital we are not allergists, we are organ- example as a gastroenterologist, if you want to specific consultants who have to do allergy with practise it at a hospital level, is six months doing diVerent passions, so I would be passionate about my allergy, to meet the burden of work that comes to you food allergies and less passionate about my asthma, in a district general hospital. but hopefully as a paediatrician I can deliver the whole package. That may not be true in adult Q687 Lord Rea: Would a general practitioner be practice where if you have got food allergy you go to able to enrol on the MSc course? an adult doctor and he may not be an adult Professor Hourihane: Yes, it is multi-disciplinary. gastroenterologist and he may not be able to help you with your eczema. Professor Hourihane: I would say that allergic Q688 Lord Taverne: Just following that up, with the conditions are diseases that live in the community but general practitioners being so ignorant about are looked after by professors in university hospitals, allergies and being in such a crucial position to refer and that is not a reasonable model of care. people, there are many pressures on their time to get up-to-date on all sorts of diVerent developments. What would be the minimum education and training Q685 Lord Rea: How long does it take for a they would need in the diagnosis or recognition of consultant in any of the specialties in which allergy allergy? What sort of base model would they have to Y plays a part to get a su cient body of knowledge in get and how long would it take them to get it? It does allergy to consider themselves well-trained as an seem to be a rather desperate situation when they allergist in their particular field? know nothing and the training courses appear to be Professor Hourihane: There are European standards so long. of training which say that they should have four years Professor Harper: It should be incorporated in part of of specialist training or so. If you take the British the core training. Not just for general practice, but in model of higher specialist training, that is two years thinking about my own specialty—dermatology— as a registrar and then three years of higher specialist there is very little provision, even nowadays, for training and many people who would go into what incorporating adequate allergy training in becoming are niche areas would do primary research at that a consultant dermatologist. I think it should be done stage, so it is at least five years as a registrar with at core level. If there are already general practitioners maybe a couple of years for higher degrees. who are out there practising, then they would need to attend courses, or undertake an MSC if they had a Q686 Lord Rea: What I am talking about is particular interest, but perhaps one particular person somebody who has already got a consultant post in within a general practice who had a particular their particular area but wanted to establish an interest in allergy could take it on. expertise also in allergic manifestations of their Dr Rosenthal: To be completely pragmatic, given the particular specialty. number of hours that GPs are compulsorily required Professor Hourihane: There is a specific allergy MSc to be educated, I would have said four hours in a year course in Southampton which can be taken in a would get you a fair way up the learning curve. modular fashion and that can be done at certificate, Dr Hyer: What you are asking them to do in those diploma or full MSc level over the course of four four hours is learn to recognise allergy because you years. So there is postgraduate training available but are going to have colleagues who will take it on. I am it is very unavailable! being a bit controversial here, but I do not expect a Dr Hyer: If you ask how long does it take: I have had GP to diagnose and manage a young child who may to train myself and I do not know how good I am be at risk from multiple food allergies. I think this because I am only trying to do the job, no-one has child has a degree of complexity that validates him validated it, I just have not made mistakes. You will seeing a specialist in hospital so those four hours are allergy: evidence 265
7 March 2007 Professor John Harper, Professor Jonathan Hourihane, Dr Warren Hyer and Dr Mark Rosenthal principally about recognition and sharing treatment, diagnosis of allergy and lead to dangerous but I still think there is a role for the hospital doctor management practice. in actually seeing them. If you had two hospital admissions with asthma and they have multiple food Q691 Chairman: Are systemic steroids allergies, surely they merit seeing Mark or another appropriately used in children? specialty or a general paediatrician to address that? I Dr Rosenthal: It depends who is doing the using. That do not know if the others agree. is not the question I expected. All medicines have to Professor Hourihane: I agree. be treated with respect, but the failure to use systemic Dr Rosenthal: I agree, the principle of the training is steroids where appropriate is as big a problem as to recognise the problem. Management is a separate using them when they are not appropriate. issue but you cannot do management without Professor Hourihane: I would say that an integrated recognition. allergy service spends more time normalising a diet rather than restricting a diet, and we take the worries of allergic disease oV families by showing them or Q689 Chairman: I would like to just finish by asking proving to them that they have not got the allergy. one short question to each of you and that is whether EVective management to address the allergic we know what the burden is of misdiagnosis or wrong components of asthma can decrease hospital diagnosis amongst allergy in children in this country? attendance by 55 per cent and medication use by 60 Dr Hyer: I can tell you from my own audit that 50 per per cent, so there is an enormous added bonus to the cent of my new referrals to my allergy services, I can tell NHS to invest in allergy services. them they do not have an allergy and send them away. Professor Harper: We have heard that eczema is often That is a significant saving bearing in mind that 10 per the presenting feature so many of these children are cent of all GP prescriptions in this country are based on referred to dermatologists and the severe ones often to some kind of atopic or allergic role. I can stop that in 50 me. It is both ends of the spectrum. I think very often per cent of the patients where they are alleged to have allergy is under-rated and perhaps missed but there is food driving their atopy, overcoming some of the also a drive from the parents themselves who have myths. I also believe if you make the right diagnosis initiated a dietor been given advice from friends,family you can help prevent hospital admissions and or someone in the high street, so it really is a subject that complications, etcetera. You are quite right; you can needs to be more expertly managed. reduce the misdiagnosis if you oVer the right service. Chairman: Could I thank you all for coming today and for all the information that you have given us. If there is any additional information that you would Q690 Chairman: Did you want to add anything? like to submit to the Committee, we would receive it Dr Rosenthal: My biggest worry is the consumption as part of your evidence today so please feel able to of what might be called fringe diagnostic things or send anything in. You are very welcome to stay and “high street quackery” that may make an erroneous listen to the next session. Thank you.
Examination of Witnesses Witnesses: Ms Joy Winks, Chair, School Nurses Forum, Royal College of Nursing, and Ms Sarah Day, Independent School Nurse Representative, School Nurses Forum, Royal College of Nursing, examined.
Q692 Chairman: Could I thank you both for coming Q693 Chairman: Can you tell us which allergies today. I am Lady Finlay and I chair this Sub- cause the most problems for children in schools and Committee and this is our tenth evidence session. I how the needs of these children are taken into wonder if I could start by asking you to introduce consideration? yourselves. As you may have heard at the beginning, Ms Winks: All the allergies actually cause work and there is a document with our declared interests so we problems for children in schools. As far as school will not be going over those again today. Would you nurses are concerned, food allergies with an ensuing like to introduce yourselves and then we could EpiPen actually cause us more work in terms of time proceed with the questions. but they are very much done on an independent basis, Ms Winks: I am Joy Winks and I am a school nurse so one care plan for asthma might take you a week to advanced practitioner in the north of the country and sort out and another one might be a very short space I am also the chair of the RCN School Nurses of time so it is very individual. Forum. Ms Day: Any allergy in school is going to aVect a Ms Day: I am Sarah Day and I work in an child. It may be that they have got to have medication independent school in Eastbourne. I stand on in school. There is an element of body image with the RCN School Nurses Forum representing eczema and how it is going to aVect that. Children do independent schools. not like to be diVerent to other children so this can 266 allergy: evidence
7 March 2007 Ms Joy Winks and Ms Sarah Day really have an eVect. They may be missing a lot of that they will turn to alternatives where they can pay school either because of bad management or because and access the facilities. Obviously I am talking about their condition is not under control. Again those who can aVord to pay for those services, and in management is down to trying to plan care. In the independent schools we do see alternative independent schools we are fortunate enough to have medicines being used quite a lot. To reassure them a large number of school nurses actually attached to again from our point of view in independent schools, schools so we can liaise closely with parents and they have a nurse on the premises, so that is things are much easier whereas with the state school reassuring to them that we do have some knowledge nurses we are signing up one nurse to 14 schools so and are able to care and look after their children they cannot work quite so easily. while they are at school. Ms Winks: The burden of our practice in the state side Q694 Chairman: Is enough being done to help is on training and supporting school staV in dealing children manage allergy, particularly hay fever with the allergies so we will have things like school suVerers? I am thinking of the examination season. Is agreements, whole-school training, protocols, and there anything that the Government should be doing individual care plans for children and it is a very centrally for such children? individual thing. A child in a huge comprehensive Ms Day: I just look at it, having listened to our school will maybe carry their medication with them professionals speak, we work down on the ground and for a child in a small primary school it will be level and if the management is not coming from kept in one place and all we could do is support and higher up then at ground level we are picking up the train, but again it is not a standard across the board bits and pieces. You could say that, no, the because of the numbers. management is not as eYcient as it could be and we have to work with the resources we have. Q697 Lord Haskel: Is there any conflict between the Ms Winks: I do feel that the school nurse, as a health Government’s current Transforming School Food professional in school, and one of the very few health initiative and the needs of food-allergic children? professionals in school, is ideally placed to help Ms Winks: There is some writing about the conflicts. schools and head teachers and staV deal with these They are going to provide nuts instead of chocolate children, but, as Sarah says, there are not enough of and things like that. I do not feel that I can comment us on the ground as health professionals in schools. particularly on that, I have not read any papers or anything about it, but it would obviously be a conflict Q695 Baroness Platt of Writtle: We are told that if that arose. because the season for hay fever is the exam season children with hay fever quite definitely are achieving Q698 Lord Haskel: Can you deal with it just by considerably less than their fellow students. What do common sense? you think ought to be done to combat that problem? Ms Winks: A lot of it is common sense certainly. Ms Winks: I think the variations are huge. In some Again we have heard the experts saying that to deny areas a child will be allowed to sit an exam at a all contact is not good so there is not even a consensus diVerent time or consideration will be taken of the of opinion there. fact that they have taken medication and in another area that does not happen. There is no consistency Q699 Viscount Simon: How are children with and I think that is the major problem. Listening to the asthma and anaphylaxis monitored during school four allergists previously it is obvious that there is a hours? problem with standardisation. Ms Day: They are managed mainly on an emergency basis. The children all have a care plan so that we Q696 Lord Haskel: There was a study published in know what they need to do in the school day and you 2003 showing that children with peanut allergy hope that it goes well and you deal with any suVered a poorer quality of life and they had higher emergencies. Again, in independent schools they anxiety levels than those suVering from, for instance, have access to nurses and boarders are obviously insulin-dependent diabetes. What is being done to monitored by the school nurses, maybe with peak reassure food-allergic children and their parents flows for asthma, who can look at skins for eczema about their safety while they are at school? and rashes and refer easier. This is a problem again Ms Day: I would say, yes, there probably is a greater for the state schools who do not have health care level of anxiety because we do seem to have diabetes professionals on a daily basis. more under our control and yet the evidence you Ms Winks: It is exactly the same, as I said before, that have heard with allergies is that there is a problem there will not be a nurse on site in the majority of the with actual diagnosis or getting hold of specialist mainstream schools and so it is about training the treatment. Again, the anxiety levels from parents staV and helping them, supporting them, making sure being unable to access specialist treatment means that they have the knowledge and the skills. There allergy: evidence 267
7 March 2007 Ms Joy Winks and Ms Sarah Day was an Audit and Healthcare Commission report Ms Winks: Virtually across the nation at the moment about how schools deal with obesity in February last school nurses are not being allowed to go on training, year, and I know obesity is diVerent but it is still a even the training for their specific degree course, for health problem and the heads there recognised that their professional training; places have been cut. they do not have the knowledge and the skill to deal Lord Rea: This is rather diVerent from the evidence with that and teachers said in that report that the lack we have had. of health professionals in school was a barrier, and it Lord May of Oxford: It is just as well they are not is exactly the same for the allergic children; it is a using the things that they need to be trained for that barrier at ground level. they are not being trained for, is it not?
Q700 Viscount Simon: What is the role specifically of Q704 Lord Rea: We heard evidence from Mr Wells the school nurse and teacher when there is an allergic from the Department for Education and Skills that emergency? How do they cope? “any nurse who administers an immunisation in a Ms Winks: The nurse in the mainstream state schools school setting will receive anaphylaxis update will not be present. training on an annual basis. That is a requirement of their own continuing professional development.” Is this an aspiration or reality? Who provides the Q701 Viscount Simon: Teachers? training? V Ms Winks: So the teacher and the sta in the Ms Day: Where you can get it from. classroom or the dinner ladies, whoever is actually Ms Winks: Some primary care trusts provide the present, will have been taught and trained and training in-house and that is why we still get it. I am practised with a dummy EpiPen, if it is an EpiPen, or fortunate that I come from a city with a children’s knows that the child had an inhaler and they will hospital and so we access the allergists for our follow the child’s individual plan. anaphylaxis training, but it will be done in-house so, Ms Day: I would probably say a high degree of yes, it is right we do have to do it and anybody anxiety at each emergency, whether it be for the administering vaccinations will have that training, teacher or for the nurse because it is a life-threatening that is standard, but it will be in-house. condition, and you have the protocols and you have Ms Day: Again, as independent school nurses we do your training but it is not something that you are not have any line management or medical dealing with every day and, like everything, there is management as such so we are having to buy into a high level of anxiety to get them to hospital care as services all the time for training. Obviously each quickly as possible. nurse is accountable but it can be a problem to try and access into the training courses depending on Q702 Lord May of Oxford: What actually is the where you are. incidence of these sorts of happenings because you have just heard Dr Rosenthal talk about—or in fact Q705 Lord Rea: Could you explain again what you maybe I read it in this—the countless EpiPens he has mean by “buy into”? prescribed and he is only aware of one of them being Ms Day: We have to pay for our training so that we used. What are we talking about here with people can practise because we do not come under the NHS, having to use an EpiPen at school? Once a year, once we are employed by the schools. every few years, once a month? Ms Winks: In my experience I have never known one Q706 Lord Rea: So it is the Department for used and I am from a large city. Education and Skills who pays? Lord May of Oxford: This is a not irrelevant problem. Ms Day: Yes, our school environment will pay for our training.49 Q703 Lord Rea: In fact, do you feel that school nurses are suYciently well-informed on how to deal Q707 Lord Colwyn: But when you give a vaccination with emergencies? I assume you know which ones are slightly risky and Ms Day: I would say probably on emergency training which ones are not? as nurses if we are giving vaccinations we are Ms Day: With any vaccination anyone can react at expected to have anaphylactic training every year. any time to anything. Obviously there are protocols However, there are not any standards that I am and guidelines for vaccines but anybody having a aware of across the nation as to the exact amount of vaccination could react at some point, in theory. training we should have so it varies again from 49 Following the evidence given by Ms Day, the Royal College of individual nurse to an individual area as to what Nursing wished to clarify this statement. The Department for training you are actually getting. At the moment Education and Skills is not responsible for training, but nurses employed by local education authority schools may get funding accessing funding to training is a problem both across from the DfES. For further information please see the the state and independent sector. supplementary evidence from the Royal College of Nursing. 268 allergy: evidence
7 March 2007 Ms Joy Winks and Ms Sarah Day
Q708 Lord May of Oxford: I gather that in 2005 the Ms Winks: There are huge variations. It will be Department for Education and Skills produced a working very well in some places and not in others. guidance document for schools—and they are very They may not know where to find it on the bookshelf good at producing documents—called “Managing in some schools. Medicines in Schools and Early Years Settings” suggesting that children with particular medical Q713 Chairman: How much is the influence of the needs should have an individual health care plan. parents’ use of complementary practitioners outside Who actually draws these plans up and do you think the NHS impacting on your drawing up of care plans V that the following through to make sure that all sta with the parents? are aware of them is as it should be? Ms Winks: I have to say in the mainstream state side Ms Winks: No, it is not as it should be. There are it is not something that I have come across or again huge variations across the country. From my something that I have heard nurses up and down the own experience of school nurses it is in their core country talking about. programme which is agreed with the Education Ms Day: I think in the independent side you go with Committee that we do other care plans and we do do the parents and if you are finding that that treatment V that and the schools will have a process for sta is not working, as a health professional you can knowing which children have got care plans. recommend other areas or perhaps turn back to the medical side and advise them where to go, so that is Q709 Lord May of Oxford: Do you think the more on an advisory state but it is a question of document itself is satisfactory? I spent five years, in a managing. The problem as well, as we have heard curious way, as a civil servant and I found some of the before, is the communication down from specialists. things quite useful and some of the things were a most We rely on the parents. We are not jumping straight tremendous waste of paper and eVort (although it did to their GPs or straight to a specialist practitioner provide employment!) Do you think this particular and we find it very diYcult to access perhaps all the document is a good and useful one? right information on which to make a validated care Ms Winks: It is useful but I do not think it was ever plan for the children. In boarding schools as well with meant to be used in its entirety otherwise you would an increasing number of overseas students obviously waste an awful lot of time and paper. Because it is an communication there is a real problem. We have individual care plan you are expected to pick out the language barriers as well as cultural diVerences and individual parts of it. A health professional is whereas we might say that the instances of peanut definitely at an advantage when you are trying to pick allergy are not high they do have a lot of rhinitis and out what is necessary. hay fever and other allergies which we are trying to manage. Q710 Lord May of Oxford: How aware are parents of this and what sort of interactions do you have Q714 Lord Selborne: I would like to come back to across the range of parents, who I imagine can range EpiPens, which we talked about in the earlier session from those who are insuYciently concerned to those as well. You have already told us that they are very who are excessively concerned? rarely used in your experience or the need rarely Ms Winks: We totally work with the parents; we have arises, but we are also advised that they are prevalent to, they are the experts in their children. and they are widely prescribed, so there must be quite a lot of them knocking around the schools and there is not a school nurse in the maintained sector, so it is Q711 Lord May of Oxford: What is your experience going to be the teacher ultimately on the rare of doing that? Does that seem to you to work well on occasions when it is used who will have to supervise the whole? it. We have been told by the Government that there Ms Winks: Like I say, there is a huge variation. We is no reason why the teacher should not deliver these will have to do home visits on some to get the care EpiPens. Do you think that this is appropriate and do plan done. Others will come into school willingly or you think they are stored appropriately in the school meet at a health centre. Obviously if a parent is not environment? going to help you with it, you can end up looking at Ms Winks: There is absolutely no reason why the child protection side of things because there is a anybody should not administer it if they actually are need for that child to access school, so you need to there. There will be a protocol for somebody staying work in partnership with people from education and with the child and somebody going and fetching the other areas. EpiPen if it is held in a certain place. There is no reason at all why a teacher should not administer it, Q712 Lord May of Oxford: But on the whole you but then there is no reason at all why a dinner lady or feel this thing is working okay, this particular bit of a caretaker should not administer it either. It will the whole thing? depend on who is at the scene at the time. As for allergy: evidence 269
7 March 2007 Ms Joy Winks and Ms Sarah Day storage, it varies hugely. In small schools they tend to EpiPens which need to be accessible; there is no point be kept in one place and the staV know exactly where in locking them away otherwise they are not to go and they send a runner. In a huge accessible. Because they are a prescription-only comprehensive on diVerent sites you cannot possibly medicine there is also an issue that you cannot have do that, so the young person is usually encouraged to a stock, so for our premises where there is a school carry it with them. nurse or even in the state school it would be good to be able to have an EpiPen and a Ventolin inhaler for Q715 Lord Selborne: Are there national guidelines emergency use but we cannot because they have to be which would be easily available? on a prescribed basis for a prescribed patient. I think Ms Winks: The Anaphylaxis Campaign do issue some that is something that could be looked at for schools guidelines and they can oVer training, if people can in order to prevent a lot of expense to the NHS on aVord to buy it, so there are some but it is only from prescriptions and it would be quite a simple thing to the charity, the Anaphylaxis Campaign. As far as I enable schools to do. know, there are not any national— Ms Winks: Wherever there is a medical practitioner or nurse on site then you could do that, but it would V Q716 Lord Taverne: Can I come back to your earlier be a di erent ball game for a teacher to be making a answer. You say you have never actually known of a decision to use a stock bottle of something. case in which it has been used. That is over how many years and with how many schools? Q720 Lord Selborne: We have heard from the Ms Winks: I have been a school nurse in SheYeld, in Anaphylaxis Campaign that they have suggested that a large city, for 15 years and we had very few EpiPens generic auto-injectors should be available in schools when I first started, in fact it was not something that where there are severely allergic children, and that we encountered, and gradually over the years we now would be available for any child who might need a have a lot of EpiPens. second dose. In the light of what you have told us I suspect that you would feel that that is unlikely to be Q717 Lord Taverne: So how many schools would needed on the whole. that cover? In 15 years you have never known one Ms Day: It is the question of unknown, is it not? We used? may not have experienced it but other people have Ms Winks: There are 70,000 school children in and every year a child dies from either anaphylactic SheYeld. shock or asthma.
Q718 Lord Taverne: Over 15 years they have never Q721 Lord Selborne: You think it would be a good been used to your knowledge? idea? Ms Winks: No. Ms Day: I think it has to be there and it is being able to recognise the symptoms in an emergency and that Q719 Lord Selborne: I wonder if Sarah Day can tell this child needs treatment straight away. us whether you think in the independent sector they are more prevalent or less prevalent. Q722 Lord Selborne: How long does an EpiPen last Ms Day: I have a school of 400 pupils and six have in storage? Can you keep it indefinitely? been prescribed EpiPens, and that is various ages. Ms Day: No. The youngest is five with an EpiPen up to the oldest Ms Winks: They do have dates on them. being 18, mainly for nuts, but also for a bee or wasp Ms Day: 18 months to two years max. sting for one of them. None of those have actually Ms Winks: It will be a part of your protocol to check. had anaphylaxis to then be prescribed an EpiPen at Lord May of Oxford: I can see that being a tension any time. That comes to the attitude that sometimes with the manufacturer who wants a short date. it can get a bit like asthma where they do not carry People do over interpret the dates on these things and their EpiPens with them because they do not know from my understanding of the functioning of the what it is like to experience something, so perhaps we EpiPen I am at a bit of a loss to see why there is a date are prescribing when they do not need it, I do not of 18 months. know. Or maybe it is better to have something there for emergency rather than nothing at all. I would like Q723 Chairman: Do we know the evidence of when to suggest something because if you think about it it actually does deteriorate? you have schools which have got all these EpiPens Ms Day: I do not know. flying around everywhere, and it is the same with Lord Colwyn: I have an EpiPen in my medical Ventolin inhalers, which you may know are for equipment and I have to replace it every 18 months asthma emergency care, and if every pupil with or two years. asthma and anaphylaxis are prescribed then the Lord May of Oxford: I am asking a diVerent schools are loaded with drawers full of inhalers and question. 270 allergy: evidence
7 March 2007 Ms Joy Winks and Ms Sarah Day
Q724 Lord Colwyn: It is expensive. In these days of worry about with the academic side. I think there is a increasing litigation doctors tend to over-prescribe lot more we can do to help. rather than under-prescribe and I think your idea of having a school store of asthma inhalant and an Q727 Baroness Platt of Writtle: What further EpiPen is a very good idea. I am surprised that you training is needed for school nurses, teachers and—as cannot do that, I did not know that. you have mentioned several times—dinner ladies, in Ms Day: No you cannot. It is a prescription-only the management of our allergic children? You have medicine so it is a diVerent legal issue. also mentioned cuts? Ms Winks: Obviously I am going to say that if we had more school nurses we would be able to do more on Q725 Chairman: It was the Anaphylaxis Campaign the public health side. Anaphylaxis is not the only who also told us that they felt the Government was aspect. We are quite high on the Government’s not adequately training school nurses, so it is agenda. We are in most of the documents to do with developing a training programme which has been public health in schools—extended schools, teenage piloted around the UK. Do you think it is necessary pregnancy, obesity, all those things—and at the for them to do this and that there is indeed a need for moment we just do not have the capacity. The RCN them to do this nationwide? did a survey, which I think you have, to say that Ms Day: It certainly would be good to have a whereas the Chief Nursing OYcer’s review said that standard nationwide. there should be one school nurse for every comprehensive and its cluster, the survey shows only Q726 Baroness Platt of Writtle: The Government one to 14 schools, and that is qualified school nurses. have also told us that it is the responsibility of the Q728 Lord Rea: I was just simply going to ask what head teacher to assess and monitor whether teachers V is the overall deficit in school nurses compared to the or support sta are capable of dealing with allergic establishment that there should be? Do we have any emergencies. Do you think that is appropriate and is information on this? this monitoring being carried out? Ms Winks: The only information that we have is the Ms Winks: I think the head teacher obviously has the Royal College of Nursing survey that was done ultimate responsibility for the children within the which said that a school and its cluster (which would school but they would not have the knowledge or the be one and maybe five primary schools) should have skill to be able to say that people are adequately one whole-time full-time school nurse, and the trained. They would be looking to be working in evidence is that there is one to 14. partnership with somebody from the NHS and obviously the school nurses at the moment are Q729 Chairman: Thank you very much indeed for virtually the only medical people that go into the coming up today. I know you sat in during the earlier schools, and so we are the link between the school session. If there is any additional information that and the specialist and anybody who is training. you would like to send into the Committee, then Ms Day: The head teachers are academic. I work in please feel free to do so and it will be considered as an academic environment all the time and there is a part of your evidence. You will also be sent the lack of understanding about the medical and the transcript for you to look through and perhaps educational side. To put the emphasis on teachers correct if you feel that you have been inaccurately and head teachers all the time to meet government transcribed. Thank you again for coming. health targets is very unfair. They have enough to Ms Winks: Thank you very much for inviting us.
Supplementary memorandum by the Royal College of Nursing
Training Budgets
Committee members were interested in the annual anaphylaxis training that school nurses receive and inquired about who has primary responsibility to provide training for school nurses. Whilst it is the responsibility of each individual PCT to ensure that school nurses receive their statuatory training requirements the RCN has concerns that, as posts remain unfilled due to financial deficits, many specialist nurses such as school nurses are finding it diYcult to be released for essential training updates. A recent RCN survey showed that almost a quarter of school nurses were unable to take time oV to undergo further training, with a lack of career progression proving a problem for three quarters of nurses. allergy: evidence 271
7 March 2007
In a survey undertaken by the RCN in October 2006 we found that 83 per cent of nurses believed training has been reduced or cut as a result of financial pressures in the NHS and over 38 per cent of nurses had study leave cancelled. Whilst these figures apply to the entire nursing workforce reports from our school nurse members reveal that financial deficits have impacted on school nurses accessing the training that they require.
Emergency Medication Stocks Our Independent School Nurse representative, Sarah Day, made a recommendation during the evidence session that schools could keep an emergency stock of inhalers and epi-pens instead of holding an individual supply for each child. This was suggested as an alternative to schools holding a large supply of individually prescribed medications which by their nature need to be easily accessible. However, as medication such as ventolin inhalers and epi-pens are prescription only medications, required to be prescribed to an individual, it would prove diYcult in the current environment for schools to hold a stock supply of emergency medication. The current diYculty is that medication is prescribed on a patient specific basis and once this has been done it would be illegal to use prescribed medication for someone else. To enable school nurses to prescribe and administer from an emergency stock of medication they would be required to train as independent nurse prescribers or work under a clinical management plan as a supplementary prescriber for each child. This would mean that a smaller emergency stock of medication could be kept on site and a school nurse could prescribe the medication to the child in case of emergency. This could work very eVectively in the independent sector or in special schools where there is generally a registered school nurse on site. However, in the state system where there is not a registered school nurse permanently on site, it will continue to be necessary for a stock of emergency individually prescribed medications to be kept on school premises for administration as per the Department for Education and Skills guidance on managing medicines in schools and early year’s settings. April 2007 272 allergy: evidence
THURSDAY 15 MARCH 2007
Present Colwyn, L Platt of Writtle, B Finlay of Llandaff, B Simon, V (Chairman) Soulsby of Swaffham Prior, L Perry of Southwark, B
Memorandum by YORKTEST Laboratories Ltd
About YORKTEST YORKTEST Laboratories Ltd is a specialist provider of food allergy and food intolerance testing, direct to the general public, and has helped thousands of people find relief from chronic health conditions during the past eight years. It uses a food-specific IgG food intolerance test to identify food intolerances which could be the cause of an individual’s ill health symptoms. This particular method was subject to scientific scrutiny in a recent clinical trial which was published in Gut Journal. A clinical research study is also due to be published shortly in the International Journal of Nutrition and Food Science. YORKTEST has worked hard to scientifically validate its testing services and has a number of ongoing collaborations with patient groups (Allergy UK, Action Against Allergy, IBS Network, Migraine Association) and clinicians in order to further explore the area of food intolerance. There is no doubt that the mechanisms involved with food intolerance are not totally understood. However, there is very clear evidence which supports the fact that food intolerance can cause negative health symptoms and relief can be found from these symptoms once the oVending foods are removed from the diet. The area of food intolerance, as with many areas deemed “complementary” health, suVers with a negative image. Many providers of such services, some even readily available on the high street, do not use scientifically validated or clinically proven tests and are therefore unlikely to oVer their customers any relief from negative health symptoms nor do they provide any health benefit. YORKTEST is keen to diVerentiate itself from the non-scientifically validated service providers. YORKTEST holds three SMART awards from the DTI, both ISO9001:2000 and ISO13485:2003 Quality Management Certificates, and the Food Allergy and Food Intolerance Testing Services they oVer are fully compliant with the European In Vitro Diagnostic Directive 98/79/EC Annex III, Section 6 (self-test) which includes the Design Examination by the Notified Body (UL International). YORKTEST also holds the Queen’s Award for Enterprise: Innovation. Despite these accreditations YORKTEST often finds itself grouped with the less reputable organisations and still finds resistance from GPs or clinicians whose patients are interested in exploring YORKTEST further. YORKTEST understands this attitude as there are many examples of non-reputable providers. However, the lack of regulation (or the lack of policing of the existing regulations) could actively be preventing people from finding relief from their ill health symptoms because of the lack of diVerentiation within the industry.
Q: What impact do allergies have on the quality of life of those experiencing allergic disease and their disease? Food intolerance, as with all types of allergy can have a negative impact on an individual’s quality of life. Many people who turn to YORKTEST have suVered with chronic conditions for many years and have found very little relief. Chronic conditions can result in time oV of work, numerous visits to the GP, and costly prescription medicines or OTC medications. From a personal perspective many people find that chronic conditions can negatively aVect their social lives or ability to participate in sports or other activities. The all encompassing nature of many chronic conditions means that people often turn to private services in an attempt to relieve their symptoms which seem unaVected by traditional methods and treatments. People simply become desperate and are keen to try anything which oVers hope. However, it is important that this “hope” is regulated in order for people to identify whether it is false or has some scientific basis. allergy: evidence 273
15 March 2007
Q: Are current regulatory arrangements, for example those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests satisfactory? — The MHRA, an agency of the Department of Health, is responsible for regulating the safety, quality and performance of self-test kits. The transposition of the European IVD Directive 98/79/EC (IVDD) and European Medical Device Directive 93/42/EEC (MDD) into UK law was enacted by a statutory instrument which in turn updates the 1987 Consumer Protection Act—and as such is criminal legislation. Food Allergy and Food Intolerance tests and testing services clearly provide information regarding pathological/physiological conditions and thereby are included in the IVDD definition of in-vitro diagnostics. — During 2004 the MHRA and the Notified Bodies jointly decided that, not only IVD products, but also IVD testing services, supplied direct to end users (consumers) without the involvement of a healthcare professional are designated as “self-test” thereby requiring Notified Body (eg LRQA, UL, SGS) audit of the technical files, and approval prior to registration and placing on the market. — Direct to consumer “self-test” testing services have had to be in compliance with the IVDD, including successful Notified Body audit and approval, since 7 December 2005. Despite these laws and regulations being in place to (supposedly) protect the consumer, there are many providers of such services who do not use scientifically validated or clinically proven tests and are therefore unlikely to oVer their customers any relief from negative health symptoms nor do they provide any health benefit. YORKTEST would welcome more regulation in this area and believes that it is a vital step in the provision of allergy services. In addition to the commercial implications YORKTEST believes quite strongly that the consumer requires protection in this area. It has been identified by the Government that allergy is an unmet need in the UK. The Government is struggling to cope with patients suVering from classical allergy symptoms; food intolerance isn’t even on the radar. Many people frustrated by their symptoms seek help from sources such as private testing services. These individuals are often desperate to find relief having suVered for many years with chronic conditions. The lack of regulation combined with a lay person’s inability to diVerentiate between these services means that the consumer often pays large sums of money to organisations which are in no way scientifically validated.
Examination of Witnesses Witnesses: Dr Gill Hart, Technical Director, YorkTest Laboratories Ltd, Mr Richard Gutowski, Head of Compliance and European Business for Medical Devices, MHRA, Ms Helen Young, Executive Clinical Director and Chief Nurse, NHS Direct and Mr Andrew Dillon, Chief Executive, NICE, examined.
Q730 Chairman: Could I start by welcoming those Mr Gutowski: I am Richard Gutowski from the who have come to give evidence to us and members Medicines and Healthcare Products Regulatory of the public who have come here today for our 11th Agency which is an executive agency in the public hearing of the inquiry into Allergy. There is an Department of Health and I have responsibility for information note in which all members of the compliance issues relating to medical devices. Committee declare their interests so we will not be Ms Young: I am Helen Young and I am the Clinical repeating those today because they are on the record Director and Chief Nurse for NHS Direct which, as already. I wonder if I might start, I am Lady Finlay, the Committee will know, is the telephone, web and I chair the Sub-Committee inquiry and I wonder if I digital television service for the NHS. might start by asking you to introduce yourselves Mr Dillon: I am Andrew Dillon and I am Chief and then we will go into the questions. During the Executive of the National Institute for Health and questions it will be really helpful if you can keep your Clinical Excellence. answers as tight as possible because we have got a lot of questions that we want to ask you, it means that we can get through them, otherwise we will have to stop. Q731 Chairman: Thank you very much indeed. I The other thing is that the acoustics in this room are wonder if I could start by asking you what types of not very good, so please speak up and speak clearly, allergy self-testing kits are available to the public and this is being webcast. Please start, Dr Hart. where they can be obtained? Dr Hart: I am Dr Gill Hart. I am the Technical Dr Hart: I can just speak about the services that York Director at York Test Laboratories Ltd and I am a Test provide. York Test provide an allergy screening biochemist with expertise in the development of test, which is an IgE test for allergy, direct to the diagnostic tests. public. The public have a sample taken, a full blood 274 allergy: evidence
15 March 2007 Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young and Mr Andrew Dillon draw by their GP or phlebotomist, the sample is Q735 Chairman: I wonder if I could ask Ms Young posted to us and we run it on a test in our laboratory. and Mr Dillon whether NHS Direct recommend the In addition, we provide a service for IgG testing, a use of any self-test kits and whether any have been service direct to the public, again a sample kit is sent subject to a NICE appraisal? out to the general public, they provide the blood Ms Young: From NHS Direct’s perspective all that sample, post it back to the laboratory and we provide we would oVer in this particular area is health the results. We are very aware that this is a huge information advice in relation to evidence that exists responsibility in that we do not provide the consumer that a call or a visit to the website could access to with healthcare professional involvement and we make a judgment about what type of product might have taken this very seriously, so much so that we be suitable and what type of questions they may wish have put our testing services through the same route to ask their general practitioner. We do not make as would be applicable to a self-test kit which was on specific recommendations to a particular product, we the shop floor in Boots and we have put it through would simply advise and give information on specific that regulatory procedure which I can tell you more questions that were asked of us. about later. Q736 Chairman: Are there any self-testing kits or Q732 Chairman: Mr Gutowski, do you have concepts that you are advising to patients who clock anything to add to that? on with allergy? Mr Gutowski: Yes, I have. The majority of allergy test Ms Young: To the best of my knowledge most of the kits are called skin prick tests and the substance in the information on our website and that we would advise test kit is inserted into the body to produce a reaction on is based on the referral to either a specialist, or, and these kits are in fact regulated as medicinal indeed, through the general practitioner. products.
Q733 Chairman: They are not self-tests, are they? Q737 Chairman: Mr Dillon? Mr Gutowski: No, they are medicinal products and Mr Dillon: No, is the short answer to your question. they are prescription only medicinal products, so they are not available to the public unless the GP Q738 Lord Colwyn: I am muddled about self-testing. initially writes a prescription, but, in the main, they Self-testing to me means something that the patient are used in testing laboratories either in general does themselves. Can you explain it? practice or in hospitals. There are allergy test kits Dr Hart: Absolutely. Self-testing in my definition is which are regulated as medical devices, and I will when a consumer receives a result, whether it be at come onto the distinction later because I think there home in doing the self-test kit that they bought in is a separate question on that, and these are in the Boots or whether it be the provision of a result given main used by testing services as you have just heard to that person from a testing laboratory. My and we are only aware, and this is from our interpretation of the regulations is that they should intelligence, of one of these kits being available to the both be regulated as self-testing services because no general public over the counter. Most of these IVD healthcare professional is involved. I think there is test kits are used by testing services where the patient great confusion about the distinction between the will send the sample to the testing house and either allergy kit or the pregnancy kit that you buy in Boots he will receive the results back or his general compared with the testing service result that the practitioner will. consumer can also access very readily over the Internet in Holland & Barrett and various other Q734 Chairman: Dr Hart, when you do IgE testing, places where people can get allergy and food do you send that result back to the GP? intolerance tests which do not appear to be fully Dr Hart: We give the customer the option of having regulated. the results sent back to the GP or not and in most Mr Gutowski: If I could add something to that, it may cases they choose not to have their results sent back be of help. The concept of the self-test kit is enshrined to their GP. In putting the services that we provide within the medical device regulations and it is based through the IVD Directive as a self-test testing on the concept that the test is carried out by a lay service, we have given evidence to the notified body person in their home environment, so they would that represents the MHRA which shows that the lay take the test, whether they have been given it by a user in this case can interpret the results that we general practitioner or purchased it over the counter, provide, or has the MHRA’s approval that the lay whether it be an allergy or a pregnancy test kit, they user can interpret the results that we provide and act will do the test at home and the kit itself will give them upon them on their own without healthcare a result at home with instructions that came with the professional involvement. kit as to how to make a determination on the basis of allergy: evidence 275
15 March 2007 Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young and Mr Andrew Dillon a colour change or whatever as to what the results of support and collaborate with groups to find out more that test is. about these mechanisms. Indeed, we have provided tests to a leading London hospital who have now Q739 Baroness Perry of Southwark: Do those shown, and this is evidence that is going to be definitions include any distinction between whether presented in Digestive Disease Week in Washington you read the result of your test yourself at home as a in May, that in inflammatory bowel disease there is lay person, or if you send the sample away and significantly higher IgG titers than in normal groups somebody expert gives you the result? and this is the first time this has been shown. In Dr Hart: I understand that in 2004 the MHRA and addition, the group has also shown independently, notified bodies jointly decided that not only IVD using our test, that people’s reported food products, that is the kits, but also IVD testing services sensitivities, i.e. filling in a questionnaire saying what are the direct end users or consumers without the am I sensitive to, correlates very very well with the involvement of healthcare professionals are IgG levels and this is particularly in ulcerative colitis. designated self-tests and it is my understanding of the It is very preliminary research and it is something that regulation that the CE marking for these services was we really hope the team at this London Hospital will given a two year extension from 2003 to 2005, so from build on. We have struggled working with others to 7 December 2005 all testing services that provide get grants to do this sort of work, but we really want results back to lay users should be equally regulated to encourage the understanding of these mechanisms as the kits that can be bought in Boots. I think that is which we know are not yet clear. what should happen, it is something that we comply with at York Test, but it is not common practice. Q743 Baroness Perry of Southwark: How often do you find negative results? Q740 Chairman: You did speak about people being Dr Hart: Yes, of course. We provide a food able to go on the Internet and get things from intolerance indicator test. Bear in mind that the Holland and so on. Are there European regulations people that come to York Test have chronic in this area? conditions. Our recent survey data, which we Dr Hart: This is the European In Vitro Diagnostic published, showed that over 70 per cent of the people Device Regulation which is what we incorporated have suVered for more than three years with their into the 1987 Consumer Protection Act. condition, so it is not a normal population that comes to York Test. What we find is that between 75 and 80 Q741 Chairman: Is your implication that the per cent of those people will have at least one positive European regulations are not as tight as the UK scoring to one of our 113 foods. ones? Dr Hart: There is confusion within diVerent Q744 Baroness Perry of Southwark: Perhaps I could competent authorities within Europe, my ask the other members of the panel, I understand that understanding is, of how the regulations are the IgE antibody tests are an established part of NHS interpreted and even within the notified bodies within diagnostic routines, is there any evidence to support the UK. the use of IgG antibody food tests? Mr Dillon: I am sorry, I have no information to Q742 Baroness Perry of Southwark: Can you explain answer the question. NICE has not looked at that to me as a lay person how the IgG food allergy test particular area. works, given that people who are not allergic to Dr Hart: For me, to support the use of IgG test, yes specific foods can still produce an IgG antibody there have been independent clinical trials which response when they eat those foods? have been carried out and published. This key one, is Dr Hart: I think when we consider the antibody the double-blind placebo controlled trial published in response to an antigen challenge we need to really Gut in 2004 by Atkinson, which was an independent think that the antibody response is only the first part study but used the York Test test. There has been a of the whole reaction. The presence of antibodies, study recently published in Nutrition and Food and this I believe is true for IgG and IgE, does not Science, another in Headache Care and, indeed, the necessarily mean disease or no disease. What does recent study that has been carried out using the make a diVerence is the complex cascade of events York Test test commissioned by Allergy UK, and that occurs after the antibody has been raised and independently audited by the University of York, what we find is that we use the IgG as a marker that used by 5,286 of our consumers has shown that a reaction has occurred, but that does not necessarily people who rigorously adhere to our diet, three out of mean that the reactions could provide a cascade four of those people are showing some benefit to their resulting in disease. We know that the mechanisms chronic conditions, so a considerable amount of for this are unclear and as a company we have tried to data. We know ourselves as a company that we do 276 allergy: evidence
15 March 2007 Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young and Mr Andrew Dillon not do a lot of aggressive advertising, we cannot do Q749 Lord Colwyn: I think that a lot of conditions that and the company has grown mainly on word of will get better with a better diet and that is of concern. mouth because people are showing benefit and we see Dr Hart: That is true. What we do find is that specific every day that there is, as we know, unmet need, and combinations of foods do show more benefit rather people are suVering and are then seeing benefit by than removing the typical foods that you might using our service. imagine are particularly responsive to allergy and it is those particular combinations that we can identify Q745 Lord Soulsby of SwaVham Prior: Can I be clear using our test. that with these tests you are measuring the molecules of IgG, you are not measuring specific IgG or IgE, Q750 Baroness Perry of Southwark: Do you ever are you? find that there is such a wide range of IgG reactions Dr Hart: We are measuring food specific IgG in our when you do your tests that the person who sent the IgG tests. kit in is almost on a starvation diet? Dr Hart: We are very, very aware of this and as you are probably aware we do provide a nutrition Q746 Lord Soulsby of SwaVham Prior: When you consultation with our service. We do find people who say, “food specific”, what foods are you looking at have a high level of reactivity, say greater than 10 specifically? diVerent foods, in our test. We treat this with extreme Dr Hart: We have a range of diVerent services but the caution and we always talk to that customer and talk main one is 113 diVerent foods. The test that we use through about how they may want to prioritise. We is an Elisa test methodology, so you can imagine that never advise removing lots of diVerent foods from purified food preparation put onto one of our Elisa one’s diet, that is very irresponsible, but we would plates is a mixture of proteins, of course whole milk suggest that they prioritise and maybe take some of will be a mixture of diVerent proteins. Unfortunately, the ones that have had a particularly high titer out in our business it is not like measuring thyroid from the diet first and see whether that benefits. In the function test where you have got a beautiful end this is an aid to management of diet and it is a international reference preparation, all laboratories little route map rather than going through the are controlled, you know exactly what they are laborious trials of elimination diet and challenge measuring, you know the normal ranges, we have not which are maybe never going to find the exact got the luxury of our higher order standards, the combination of foods that people are intolerant to. international reference preparations. So that putting This is an aid to management of diet and a route map the foods on the plate we have got a wide range of through for the consumer to help them. fruits, vegetables and the key foods on the plate, that is what we use. Q751 Baroness Platt of Writtle: How do the medical devices regulations and medicines licensing Q747 Lord Colwyn: I do not particularly want to legislation regulate the production and sale of allergy concentrate on Dr Hart all the time, and I apologise testing kits? to the others, but you mentioned the report Mr Gutowski: I would stress at the outset that the commissioned by Allergy UK, we have got a copy of medical devices regulations simply regulate the it here, I wonder if you could tell us if it is published? testing kits if they are placed on the market as an Is it being shown in a professional journal yet? IVD. The Medicines Act will regulate the kits if they Dr Hart: It was published at the beginning of are placed on the market as a medicine. The two sets February in the Journal of Nutrition and Food of legislation do not regulate in any way the service Science. provider or the treatment regime. There are two avenues. If it is placed on the market as a medicine, Q748 Lord Colwyn: You talk about “chronic that is normal—the skin prick test—and they are medical conditions”, but it is quite unspecific. prescription only medicines, they must meet all the Dr Hart: That is the interesting area in terms of the requirements of the Medicines Act in terms of safety, type of people who come to York Test with chronic quality and eYcacy. If the kit is an in-vitro diagnostic conditions. As you can see from the paper it clearly device, that is a medical device and it must meet the outlines the diVerent sorts of conditions that people requirements of the medical devices regulations. The do come with and because I understand that in the two regimes are very diVerent in that if the kit is a medical community people are used to looking at medical device the manufacturer must be able to specific conditions, it is very diYcult to sometimes substantiate his stated claims for the product in terms understand the concept that one or two diVerent of safety, quality and performance and must provide factors like removing food from the diet could benefit the data to substantiate that. The kit that is placed a range of conditions. on the market as a medicine must have a licence allergy: evidence 277
15 March 2007 Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young and Mr Andrew Dillon under the medicines Act granted by, in the UK, the Dr Hart: Yes, it happens to us. Essentially, we MHRA. If it is placed on the market as an IVD, comply with the essential requirements of the IVD the regulations are slightly diVerent in that the Directive which is all to do with fitness for purpose. manufacturer aYxes a CE mark of conformity, It includes looking at analytical performance data having gone through the various processes laid down of specificity, reproducibility, cross-reactivity and in the regulations. If it is a highly critical test, he must sensitivity and, from my point of view, also clinical have an EC certificate of conformity from what is eYcacy because I think not all IgG tests are the same. called a notified body. That is, a third party There is a very fine balance between the positive and independent certification organisation and they are the negative and whether they are measuring specific designated by the competent authorities in each or non-specific binding. It is very important that Member State. Unlike the medicines legislation, the there is regulation. We do comply with essential medical devices legislation is based on mutual requirements of the IVD Directive and under that we recognition so a manufacturer based in Greece can have to look at reproducibility. Yes, we have been CE mark his test kit in Greece and that has access to scrutinised and questioned about this but we have the European Community. Each of the notified evidence to show that our test is reproducible. bodies is designated for competence in this area of allergy test kits. They must prove to their designated Q754 Lord Colwyn: You survived? authority that they have the competence to assess Dr Hart: Yes, and we are here still. those kits. I am informed that there are 80 notified bodies across Europe, but only 18 of those have the competence to deal with allergy test kits. Q755 Viscount Simon: How often is NHS Direct contacted about allergy related conditions and what are the most common queries sought? Q752 Baroness Platt of Writtle: Allergy tests using Ms Young: The diYculty for NHS Direct in techniques such as hair analysis and electromagnetic answering that specifically is that the service is field detection, we understand, are not covered by the symptomatic based. In other words, when a caller or medical devices regulations. Do you think that the a person activating the website makes contact with scope of the regulations should be broadened to us, they are presenting us with their most common include these products too? or urgent symptom. What I have tried to do in Mr Gutowski: I am not too sure as to why they are not answering this question is to attack it from both included. If they meet the definition of a medical directions. We estimate that we receive over 600,000 device and an IVD, they would be included under the calls per month to the service and probably in excess regulations. of a million hits to the website per month. Of those Dr Hart: There seems to be confusion still as to the calls, for instance, allergies might present as either provision of a kit that somebody uses at home to severe breathing diYculties or diYculties with an interpret results and a testing service. What we are airway. Those two particular groups will probably talking about is Vega testing and others. Those are lead to an urgent 999 call if the caller was in diYculty. not kits that people have at home or use and interpret The other allergy related inquiries that will present as the results on their own. They go into a shop or a are wheezes, rashes, nasal congestion et cetera, again clinic and have that service provided without the aid dependent on seasonal diVerences. All of those calls of a health care professional. That is the area that are likely to be or could be allergy related. We have there is confusion over at the moment. My four specific algorithms that are launched directly as interpretation of the IVD Directive was that testing a result of a caller saying they are calling in relation services were covered by the IVD Directive for self- to an allergy query, two for adults, one for a toddler test and that is how I have put through our and one for a child. We have hard data on how many compliance, but it is quite clear that that is not times we launch those algorithms. Interestingly, happening. This is not being policed and I think it is those numbers are significantly lower than I expected very important that it is regulated in future. to report to you. For instance, those four algorithms that I have mentioned—two adult, one toddler and Q753 Lord Colwyn: Anybody who provides a self- one child—are only launched approximately 2,000 testing system or a system that goes oV to be analysed times in a year. That is not helpful to you because and charges money for it will eventually come under clearly that is masking the fact that the calls that the scrutiny of the press. I remember my friend, are about wheezing, breathing diYculties, nasal Stephen Davis, who used to do hair testing, having congestion are likely to be allergy related. We have terrible trouble with apparently two lots of hair from anecdotally looked at what nurses are doing and the same person producing totally diVerent results. what types of calls they are taking. Anecdotally, I am Has this happened to you? Is it likely to? How do you going to report that about 50 per cent of the calls that cope with it? we take that either turn out to be allergy related 278 allergy: evidence
15 March 2007 Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young and Mr Andrew Dillon because the caller says they are, or turn out to be will review the evidence behind it and submit that allergy related because we assess them as so are subsequently to the Committee. related to allergies in direct response to taking medication. The other 50 per cent can be broken Q759 Lord Colwyn: Mr Dillon, I wonder if you down into allergy reactions and are likely to be due to could update us on the submitted proposals from the food, non-food such as substances used in the Department of Health to NICE on the development environment or seasonal diVerences such as hay fever of allergy guidelines? Have you any news on those and pollen. All of these combine with problems with and when they might be published? nasal congestion, eyes, rashes, et cetera. Above and Mr Dillon: NICE is already producing a clinical beyond that, I can give you a breakdown of the guideline on asthma in children. We have been allergy related algorithms that we launch. We see 75 consulting on that and we will publish a draft of that per cent of the calls that we take pertaining to adults in the summer of this year and we will publish over the age of 17 years. 14 per cent of the calls that the guideline, subject to our consultation, in we are taking in relation to allergies are bracketed December. We have also published a number of within the 5 to 16 year old related callers and about recommendations on the use of inhalers for treating 12 per cent pertain to those calling where the child asthma and drugs for treating eczema. The would be under the age of four. That is as Department of Health had asked us to consider the comprehensive an answer as I can give you based on slight oddity in the way in which topics are the type of service that we are. considered and approved for NICE. There is a process which involves consideration by NHS Q756 Viscount Simon: I understand the 999 response clinicians and others of the potential topics right you have given but how do your staV recognise across the range of services that the NHS provides. A a condition such as anaphylaxis and drug short list goes to ministers. Ministers consider which hypersensitivity reactions and how is the adequacy of of those they wish to refer to the Institute. The DH their advice audited? itself though at a policy level can feed into the start of Ms Young: We absolutely recognise life threatening that topic selection process and they have done that symptoms and those are the ones that can go to 999. for the allergy related topics. Those topics have Whatever the call of the life threatening symptom, it migrated their way through the system and are now may well go to 999. Anaphylaxis is an issue that we back with the Department of Health and ministers would obviously be able to assess. In some cases we for consideration. They have not yet been referred to will give what I will loosely call first aid advice there the Institute and I do not as of today have any and then to alleviate the condition in waiting for the indication of when they might be referred to NICE. ambulance to arrive or in waiting to get to an urgent Assuming they are referred some time during 2007, GP or vice versa. In relation to how we assess we would then slot them into the first available our performance, our success and our clinical guideline development opportunity and if we can eVectiveness, all our calls to NHS Direct are recorded start them all in 2007 they would all be published at and subject to peer review. A selection of the calls our some point before the end of 2009. nurses take will be peer reviewed by a supervisor and usually another clinician. We do pick up where the Q760 Lord Colwyn: Are the Royal Colleges practice either needs to be improved or where we involved? have it wrong or where a nurse had indicated that we Mr Dillon: Yes. The way we develop clinical have gone down one algorithm. We just check that it guidelines is to do it in conjunction with the Colleges. could not have been something else. The guidelines are developed through a series of national collaborating centres and these centres are collectives of the medical Royal Colleges and the Q757 Chairman: On the NHS Direct website, am I other main, national, professional bodies. right that there is advice on peanut avoidance for pregnant mothers and infants from families with a Q761 Lord Colwyn: Do you have any view on how history of allergies? these guidelines will fit into the current system of Ms Young: Yes. allergy service provision in view of the financial constraints of most PCTs? Q758 Chairman: I wonder why that is still there and Mr Dillon: They fit into the existing services in that what evidence there is, given that that is now they would represent standard good practice, so the disputed advice? existing services would do what the NHS does Ms Young: I do not specifically have evidence in front generally when NICE produces a clinical guideline. of me today to refute that or reply to that but I am That is to base line current service provision against willing to submit some evidence. I will review it and I recommendations and develop in eVect a project plan allergy: evidence 279
15 March 2007 Dr Gill Hart, Mr Richard Gutowski, Ms Helen Young and Mr Andrew Dillon to migrate towards broad accordance with those Mr Gutowski: I can answer it very briefly in the sense recommendations. They also have the eVect of that the Committee on Safety of Medicines within the stimulating the creation of services where those UK restricted the use of desensitising vaccines in, I services do not exist. There have been examples from am told, about 1986 and 1994. They advised of other NICE clinical practice recommendations inadequate evidence of benefit to support the use of where that is happening. Clearly the NHS is expected these vaccines. They revisited that in 1994. They to do an enormous amount for all of us and we all recommended that these treatments should be expect it to do all of that straight away. The reality is restricted to those patients who have not responded that local NHS organisations start from diVerent to anti-allergy drugs. I can give the Committee a positions for individual services. Some are well more detailed explanation of the thinking behind the advanced in one service and less well advanced in CSM’s decision in this respect but I do not have any another. The time it takes to get from where more detail of that in front of me. somebody might be at the point at which we publish a recommendation on a particular aspect of clinical Q765 Lord Soulsby of SwaVham Prior: One practice to being able to say, “We are consistent with wonders, for example, whether NICE have NICE recommendations” will vary. That variation carried out an appraisal of allergen injection is in part also a result of the ability of NHS immunotherapy. Mr Dillon, have you any organisations to allocate resources to implement information? what we have recommended. Mr Dillon: No.
Q762 Lord Colwyn: I suppose we might be Q766 Lord Soulsby of SwaVham Prior: In view of the concerned that there is such a shortage of allergy more general use of it in other countries in Europe, is consultants throughout the country that services it not worth looking at in greater detail than hitherto? might vary from region to region. Obviously its use has been rather negated by what Mr Dillon: They do. It is not just because of the you say. distribution and number of allergy consultants. Mr Dillon: Anything that the NHS can and does Most allergies can be very competently managed oVer, regardless of at whatever level and whatever in primary care by generalists and that is where variation, is worthy of some consideration but with the majority of service delivery will be. NICE limited capacity NICE has to prioritise what it looks guidance though would recognise both where it is at at any one point in time. That said, the process that appropriate for generalist practitioners, both medical we operate to generate topics allows anybody to and nursing, and indeed whether other health suggest either a specific drug or another intervention professionals can make a contribution to treating or a whole disease area as being suitable for and where it is necessary to refer on to more specialist consideration. The new arrangements that we have care. One of the benefits of having that guidance is put in place since the autumn of last year provide a that it gives the service as a whole, as well as local much more transparent, objective approach to NHS organisations, the ability to work out what they assessing the suitability of topics suggested and a actually need in order to deliver a good quality much more objective approach to prioritising them. service. We could do it but in the end we have to make sure that we spread our available capacity across the whole range of diseases and conditions that people Q763 Chairman: We have heard of GPs drowning would expect. under guidelines. Mr Dillon: They are but the only ones they really need Q767 Chairman: The Cochrane review came out are ours, so they need not drown. with quite positive results. How much of the Cochrane review is informing your process, Q764 Lord Soulsby of SwaVham Prior: Can we turn particularly your guideline development? to immunotherapy? We have heard from other Mr Dillon: Looking at what Cochrane has produced witnesses that immunotherapy is not very popular, if is one of the first steps that the guideline development that is the proper word, in this country compared group take in assembling the evidence. Cochrane is a with countries in the European Union. One wonders very important source of our studies and their why this is so. Is it because the MHRA regulation for database would be searched as a matter of routine by immunotherapy licences are particularly stringent the guideline development group. compared with those in other countries? There has been a visit to Germany, for example, where the Q768 Lord Colwyn: Have any of you a kind word Committee found that immunotherapy was quite about Vega testing or kinesiological testing or frequently used. homeopathic treatment? 280 allergy: evidence
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Ms Young: I cannot oVer an opinion from NHS Ms Young: It would be a personal view that they are Direct’s perspective on that. I would not feel a very important part of allergy management as are comfortable doing so. general practitioners but, because of the increase in Mr Dillon: I do not have any unkind words but I do the usage of products over the country and the not have a view. quality of advice that needs to go with that, it is certainly worth consulting with that group because they play a particularly important role in self-care Q769 Chairman: Can I go to over the counter management. medication, second generation antihistamines and potent nasal corticosteroids? These are now available from pharmacies in the high street. I wonder whether Q771 Chairman: You mentioned just now that you you feel—I guess it would be particularly Ms would advise a caller to look at a particular group of Young—that the level of regulation is right or drugs perhaps in terms of managing their condition. Do you advise them to seek advice from a pharmacist whether there is an over-availability or an under- or do you advise them to go to their GP before availability? purchasing drugs from that group? Ms Young: in relation to whether the regulation is Ms Young: It depends on the nature of the call. In right, it is probably not directly my sphere but what V urgent symptoms that we believe need to be seen by I could perhaps o er is that it is our experience that, a GP, we would automatically screen and send to the from a user perspective, the patients’ perspective, general practitioner. Roughly speaking, about one both the availability of these products and their usage per cent go to 999. 50 per cent of the calls that we take is significantly both valued and used. Although NHS in relation to allergy will end up either directly going Direct do not prescribe over the telephone and we do to a GP practice or some form of out of hours care. not directly advise patients to go and take a The rest of it will be self-care. We will say that a particular drug, we do advise on groups of drugs that particular group of drugs might be helpful in might be helpful in managing their symptom or their alleviating symptoms. We will then advise them to go condition. It has been fedback to us and it is our to the pharmacy, speak to the pharmacist and be nurses’ view that the availability of the products plus advised on what is the best product. The diYculty for importantly the pharmacists’ advice on the usage of NHS Direct is that we are not always face to face so those products is very much valued by patients. our advice to go to a pharmacy is often based on Whilst I would not personally have a comment on whether we have a view on what group of drugs will regulation, I would say that the availability and usage work but we would obviously want another clinician of such products has certainly increased, as you to have a face to face opportunity where that patient would expect. It is a favourable option for many is exhibiting a rash et cetera. members of the public and unblocks other parts of the NHS for other care. Q772 Chairman: Do you think the pharmacists have Mr Gutowski: The move of products from clinical training appropriate to the diagnosis of these prescription only to pharmacy status was following sorts of conditions? careful consideration by the Agency as part of the Ms Young: I cannot specifically comment on general policy of making more treatments available pharmacist training. I only know about our to the general public, rather than by a general collaboration with them in relation to sending practitioner. It was based on a number of patients or callers to them. considerations: a favourable safety profiling in respect of diagnosis and misdiagnosis of these Q773 Viscount Simon: Novel therapies for allergic products. The lack of abuse potential is another diseases are currently being developed such as consideration in making that determination and then anti-IgE therapies and sublingual desensitisation there is the convenience of the availability of vaccines. Are these being appraised by NICE or products from a pharmacy or general sale. When the MHRA and who can administer them? consultation was made with regard to moving these Mr Dillon: We are looking at one of these therapies products to pharmacy status, there was no objection called omalizumab and it is for treating severe, raised with the Agency with regard to the new persistent, allergic asthma. The plan at the availability of these products. moment, subject to appeal, would be to publish recommendations about the use of it in August this Q770 Chairman: Does this mean pharmacists are year. now managing allergy? Mr Gutowski: I do not know. I cannot answer that Q774 Chairman: Do you have any view on the role question. of pharmacists in the diagnosis of allergy? allergy: evidence 281
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Mr Dillon: Not from the NICE perspective but there Q776 Chairman: I wonder whether you anticipate will be a general view inside the Institute that that NICE might be evaluating some of the oral hay pharmacists have an important role to play in fever vaccines such as Grazax, whether that is on delivering services and that role over the years has your “to do” list or whether it has not yet featured. increased and is likely to increase further. The Mr Dillon: It is not on our “to do” list. It has been judgment is all about risk set against convenience for something that we have looked at and tested against patients or individuals accessing a pharmacy as the selection criteria for topics for the Institute. At opposed to going to a GP. the time we did that, it was looked at by what was then the joint NICE Department of Health Q775 Chairman: Dr Hart, from the people who are Committee in September last year. The view was that sending in to you, do you have a feel for how many have sought advice from health care professionals, it was not suitable for appraisal by the Institute. other than going through their GP, and have found Chairman: If none of you has any particular that advice helpful or unhelpful? comment to make where you disagree with Dr Hart: I do not have exact numbers or details. something said by somebody else on the panel, could People who come to us have suVered for a long time I thank you for having come this morning. If there and they tend to come to us as for other therapies as are additional pieces of information you would like more of a last resort because they do not feel their to send to us, please do. We will look at them as part needs have been met. of your evidence today.
Supplementary memorandum by YORKTEST Laboratories Ltd
Nomenclature Medical opinion recognises that food intolerance/sensitivity exists. However, because there is no agreed nomenclature there is confusion about what various parties are claiming or even discussing. An agreed nomenclature used to clearly define food allergy, sensitivity, intolerance etc would be beneficial.
Unmet Medical Need There is a huge unmet medical need for people who suVer from food “sensitivity”. The provision of validated testing services would reduce NHS costs, and allow people to make informed choices to enable them to lead more productive and satisfying lives.
Policing Testing Services All medical tests and testing services should go through an agreed validation process before being oVered to the general public. Specified bodies should be responsible for ensuring that all tests available to the public have gone through an agreed scientific validation process. Organisations providing testing services to the public should be regularly audited.
Existing Regulatory Requirements YORKTEST has fully met the regulatory requirements in providing a self-test testing service by ensuring the whole testing service is compliant with the IVD directive 98/79/EC annex III section 6 (self-test). We know that this is not common practice, but we have understood these regulations to be compulsory.
YORKTEST’s Position YORKTEST, a small laboratory, has made every eVort to ensure that food-specific IgG testing carried out at its laboratories complies with necessary regulations and good clinical practice. YORKTEST has encouraged academic bodies to undertake research into IgG testing and its role in identifying food intolerances. A double- blind placebo-controlled study was published in the international journal GUT, an audit of migraine suVerers was published in Headache Care, and just recently (last week) a major audit of over 5,000 people who had taken a YORKTEST food intolerance test was published in the journal “Nutrition and Food Science”. 282 allergy: evidence
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While we recognise that many people in the medical profession are not yet convinced of the role of IgG as an indicator of food intolerances, and we do not fully understand the mechanisms involved, we have proven that three out of four people who follow the advice given by the YORKTEST test report, get significant relief from their symptoms.
Large Number of Unqualified Tests Available A large number of tests are available to the public that have no scientific basis or have never been validated. For example, the use of electrodermal testing (Vega test) for determining whether an individual is intolerant to a particular food has absolutely no basis in science, yet it is widely available, not only through complimentary or alternative healthcare practitioners, but also in walk-in clinics and health food shops on the high street.
Confusion The public are frequently confused by the vast range of tests available. The regulatory control over testing services outside of the NHS is woefully inadequate, especially if the test is not validated and is not accompanied with any interaction with a health care professional.
The Lack of Regulation The lack of regulation (or lack of policing of the existing regulations) could actively be preventing people from finding relief from their ill health symptoms.
Choice and Taking Responsibility Giving patients more choice about how, when and where they receive treatment is one cornerstone of the Government’s health strategy. Patients should be able to take more responsibility, and have access to tests that can empower them, not potentially damage them. The consumer needs to be suitably protected.
YORKTEST Supports Regulation YORKTEST support the view that a system of regulation is needed to assess the eYcacy and to assure the quality of such testing services, particularly if they are being accessed directly by the public.
MHRA Policing of Testing Services Direct to the General Public There is clearly considerable confusion about the regulation of testing services, within the MHRA. YORKTEST calls for: (1) A Competent Authority to be set up to regulate diagnostic testing services. (2) That all testing services should go through an agreed validation process before being oVered to the general public. (3) Organisations providing testing services to the public should be regularly audited. Reference should also be made to the report that is about to be issued by the Science Council’s Science in Health Group Integrated Diagnostics project.
Clinical Trials (Food-specific IgGTesting) While YORKTEST as a small company has encouraged academic bodies to undertake independent research into food-specific IgG testing and its role in identifying food intolerances, there is a clear need for a great deal more research to better understand the mechanisms involved in non-IgE mediated food allergy. The independent studies which have been carried out include a double-blind placebo-controlled trial in IBS published in GUT which, for clarity in response to other statements made during this inquiry, showed that the number needed to treat for compliant patients was 2.5. allergy: evidence 283
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Two more independent randomised controlled trials (RCT) in IBS are scheduled for completion this year and funding is being sought from the Clinical Trials Unit at the University of York for an RCT in Migraine. Studies into IgG testing in Inflammatory Bowel Disease are being presented at Digestive Disease Week in May 2007. In February a major audit of over 5,000 people who had taken a YORKTEST food intolerance test was published in “Nutrition and Food Science”. The feedback YORKTEST has received demonstrates that many people in the medical profession are not convinced of the role of IgG as an indicator of food intolerances. YORKTEST does not claim to fully understand the mechanisms involved, but the trials, surveys and anecdotal reports consistently show that three out of four people, who follow the advice given by the YORKTEST test report, get significant relief from their symptoms.
Scientific Advisory Board In order to provide scientific support for their services, YORKTEST established a Scientific Advisory Board of independent scientists, leading medical consultants and dieticians to advise the company on clinical trials, exploring the science behind the various tests as well as reviewing and advising on the supporting materials and advisory services oVered by YORKTEST to its customers.
Unmet Medical Need There is a huge unmet medical need for people who suVer from food “sensitivity”. The wider provision of properly validated testing services would reduce NHS costs, and allow people to make informed choices to enable them to lead more productive and satisfying lives.
Supplementary letter from the Medicines and Healthcare products Regulatory Agency (MHRA) The Committee for Human Medicines (CHM) has reviewed license applications for three allergy immunotherapy products in the last two years. Each application is assessed based on the scientific evidence provided and taking into account the current prevailing medical/scientific opinion. One received a positive opinion (Grazax) and the two others were unable to show a positive benefit:risk ratio, either due to inadequate clinical data (due to testing over only a single pollen season and no confirmation of eYcacy) or unacceptable side-eVects. The answers to your further questions are as follows:
1. What subcutaneous and sublingual immunotherapy products currently have a UK product licence? Grazax (Timothy grass) is a sublingual immunotherapy product and Pollinex (grasses and rye, or tree pollen) and Pharmalgen (bee/wasp venom extract) are subcutaneous immunotherapy products which currently have UK product licences.
2. For which type of patient can these approved immunotherapy products be used, and who can administer the treatments? Grazax is for patients with hay fever with positive skin test to Timothy grass. Pollinex is for patients suVering from seasonal hay fever who have failed to respond to standard anti-allergy medication and Pharmalgen is for patients with hypersensitivity to bee/wasp venom. Grazax is an oral tablet for sub-lingual (under the tongue) administration. Treatment with Grazax is initiated by physicians with experience in treatment of allergic diseases and the first tablet is taken under medical supervision (20–30 minutes). After this, the patient will be able to self-administer the medicine, according to the instructions. The Pollinex preparations are given by sub-cutaneous injection and are therefore administered by a physician. Treatment of patients should only be carried out where full facilities for cardio-respiratory resuscitation are available. These preparations are contra-indicated in patients with asthma. Pharmalgen is administered to patients with confirmed hypersensitivity to bee/wasp venom by sub-cutaneous injection. Treatment of patients should only be carried out where full facilities for cardio-respiratory resuscitation are available and special care should be taken in patients with asthma. 284 allergy: evidence
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3. Are there no plans in the near future to review the 1994 decision to limit the use of immunotherapy treatments? CHM advises MHRA on license applications on the basis of assessment of the scientific evidence provided by the company and taking into account the current prevailing medical/scientific opinion. The license for Grazax illustrates the fact that there is no fixed view on any product class and scientific evidence is the most important determinant of the regulatory decision(s).
4. In particular, is it true that the MHRAS still advises that patients have to remain under medical supervision for at least one hour after each injection whereas in most other countries this is usually 20–30 minutes? No. MHRA approved the recommendation in Grazax product literature that observation for 20–30 minutes is suYcient. Product literature for the older products, Pollinex and Pharmalgen, recommend observation for 60 minutes after treatment, but the Marketing Authorisation Holder is entitled to apply for a variation to the license to change this recommendation, if required.
5. What criteria do immunotherapy products have to meet to be granted MHRA approval, and how do these criteria compare to those used by regulatory authorities in other countries? The products will need to establish quality, safety, eYcacy and a favourable benefit: risk profile, as for any medicinal product. This does not fundamentally diVer from other regulatory agencies.
6. Does the MHRA use the mutual recognition process to assess immunotherapy products in the same manner as other treatments, and if not, why not? UK uses mutual recognition procedure for these products in the same manner as other treatments.
7. What is the present MHRA policy regarding the prescribing of unlicensed immunotherapy products (manufactured both within the UK and abroad) on a “named patient basis”? In the UK an unlicensed relevant medicinal product may only be supplied in accordance with the provisions of Schedule 1 of The Medicines for Human Use (Marketing Authorisations Etc) Regulations 1994 [SI 1994/ 3144], (the MA Regs) Schedule 1 exempts from the need for a marketing authorisation a relevant medicinal product which is supplied to fill a “special [clinical] need” and in response to a bona fide unsolicited order, formulated in accordance with the specification of a doctor, dentist or supplementary prescriber and for use by his individual patients on his direct responsibility. In the interest of public health the exemption is narrowly drawn, because these products, unlike licensed products, may not have been assessed by the Licensing Authority against the criteria of safety, quality and eYcacy. In practice, subject to the normal legal requirements, prescribers are free, on their own direct personal responsibility, to prescribe whatever unlicensed products they believe appropriate to meet the special clinical needs of their individual patients in the absence of a suitable equivalent licensed product being available. However, the MHRA recommends that wherever possible a product licensed for the UK market should be preferred.
Memorandum by the Royal National Throat Nose and Ear Hospital (RNTNE) The RNTNE hospital is the national centre for ENT, treating annually some 60,000 patients, referred locally and from all over the UK. It is recognised internationally as a centre of excellence. Allergy is a form of dysregulated immunity such that antibodies of the IgE class are formed against harmless molecules (allergens) eg house dust mite faecal proteins, grass pollen and cat dander. Subsequent allergen contact causes a reaction involving mast cell degranulation and release of powerful mediators resulting in eosinophilic inflammation. Several thousand allergic individuals are seen at RNTNE, predominantly with rhinitis, ie inflammation of the nasal lining. The prevalence of allergic rhinitis has quadrupled since the mid 20th century and now aVects one in four persons in the UK. The prevalence is continuing to increase in many parts of the world. The reasons for this are uncertain—the hygiene hypothesis may explain early onset rhinitis, but is unlikely to account for its later development. Other possible factors include pollution, diet and persistent infection and need investigation. allergy: evidence 285
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Rhinitis, which can be allergic or non-allergic, ranges in severity from mild intermittent symptoms of rhinorrhoea, itch, sneeze and nasal blocking to severe, persistent problems with marked eVects on quality of life, greater than those attributable to mild or moderate asthma. Secondary eVects of rhinitis include development or exacerbation of asthma, sinusitis, otitis media with eVusion, pharyngitis, sleep problems, and vocal dysfunction. At RNTNE these severe forms of rhinitis form the major part of those seen by the Allergy service led by Dr Glenis Scadding. Using medical treatment, including allergen avoidance, the need for surgery in conditions such as rhinosinusitis, nasal polyposis and otitis media with eVusion has been considerably decreased and quality of life has been improved for suVerers. A beneficial eVect of upper respiratory tract therapy upon concomitant asthma has been noted. If it were possible to improve diagnosis and treatment of rhinitis in its early stages the need for these patients to be seen in secondary care could probably be reduced.
Government Advice
The setting up of asthma clinics with standardised management in primary care is an undoubted success but does not include allergen recognition nor rhinitis management. Unfortunately rhinitis is often trivialised or overlooked, misdiagnosed and mistreated. Rhinitis is present in about 80 per cent of asthmatics and contributes to airways hyper-reactivity, with retrospective studies demonstrating significant benefit such as reduced A&E visits and hospitalisation from rhinitis therapy. A recent survey of General Practitioners with an interest in airways diseases (General Practitioners in Airways Group, GPIAG members) showed that few knew the symptoms of rhinitis, very few were aware of tests to substantiate a diagnosis of allergic rhinitis or were capable of treating it adequately. GPs should have the recognition and therapy of rhinitis added to their supervision of asthma patients. Another reason to improve allergic rhinitis care is the possibility of its progression to asthma. This is preventable in children by appropriate specific subcutaneous immunotherapy (SCIT). Recently sublingual immunotherapy (SLIT) has been shown to be of proven benefit for rhinitis in a Cochrane meta-analysis. Preliminary results suggest that this form of treatment may also prevent disease progression as well as reducing symptoms and the need for other medication. There is an urgent need for large well-controlled studies to validate this, to examine the doses of allergen needed and to look at pharmaco-economic implications since this form of immunotherapy is safer and more convenient—it can be carried out by the patient at home after initial dosing in a setting with resuscitatory facilities. A further area of interest and promise is the interaction of infection, particularly with rhinoviruses, and allergy. The combination of allergic sensitisation, allergen exposure plus a rhinoviral cold result in a twenty fold risk of a child being hospitalised for asthma. Similar disease exacerbation of nasal polyposis occurs with viral colds suggesting synergy between two diVerent inflammatory processes which requires further study.
References [not printed].
Memorandum by the Institute of Food Research (IFR)
The Institute of Food Research (IFR) is an independent research organisation, with charitable status, sponsored by the Biotechnology and Biological Sciences Research Council (BBSRC). IFR’s mission is to undertake international-quality scientific research relevant to food and human health, and to work in partnership with others to provide underpinning science for consumers, policy makers, the food industry and academia. IFR has two research programmes relating to the subject of this inquiry, and this response was written by Dr Clare Mills who is the Programme Leader on one of these. IFR welcomes the opportunity to respond to this Inquiry. Reference is made in the text to EuroPrevall. This is a European-funded Framework 6 Intellectual Property project which is aiming to define the prevalence and cost and basis of food allergy across Europe. 286 allergy: evidence
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Defining the Problem 1. Allergies are a disease state which results from malfunctioning of the immune system. They can involve either cellular of humoral (antibody) based reactions. With regards to food allergies, the European Academy of Allergy and Clinical Immunology50 classifies them in the context of many adverse reactions to foods, including IgE-mediated allergies (sometimes also referred to as type-I hypersensitivity reactions) and non-IgE mediated allergies. Coeliac disease is the best characterised on the non-IgE mediated allergies; there may be others which have not been clearly defined involving the humoral and/or cellular immune system. In the EAACI classification immune-mediated allergies are distinguished from non-immune mediated food intolerances which include lactose intolerance and other undefined but reproducible reactions to foods. The evidence given below is focussed on food allergies rather than respiratory or other types of allergies, although the diseases are often connected. 2. IgE-mediated food allergies, like other allergies, involve a sensitisation phase, where an IgE response is generated towards an environmental agent (pollen, dust, food) in a susceptible individual. Predisposition towards developing IgE is associated with a polarisation of T-cell responses towards a Th-2 phenotype. However, the mechanism whereby one individual, and not another, begins to develop IgE towards an agent is not clearly understood. It may be that during early life the immune system is plastic and that interaction with microbes and infections may play a role in avoiding the development of an atopic phenotype. Much of the ideas surrounding this are presented in the “Hygiene Hypothesis”.51 There is also an emerging issue with regards to nutritional status and development of allergy. The development of the allergic phenotype has a clear genetic element and eVorts are underway to identify genetic markers related to development of allergy although this is very much in its infancy with regards food allergy. 3. Following sensitisation of an individual an allergic reaction may be elicited on subsequent exposure to an allergenic agent. The mechanisms whereby this occurs are generally well understood. However, the mechanisms underlying interactions with other factors, such as those in exercise-induced anaphylaxis (a symptom which can be associated with food allergies) are less clear. In addition the food allergies of some individuals (especially young infants) resolve whilst for others there can be a rapid progression from mild to severe reactions. The mechanisms underlying the evolution of allergies responses in this way is not understood and is hard to predict, presenting a problem regarding management of food allergies for the individuals concerned.
Why is the incidence of allergy and allergic diseases rising? Why does the UK in particular have such high prevalence of allergy? 4. Estimates of the prevalence of food allergy are generally imprecise. Many studies have not used unselected populations and none have employed the “gold standard” for diagnosis of food allergy, double blind placebo controlled food challenge (DBPCFC)52 as there are many shortcomings with current serological approaches to diagnosing food allergies.53 Such a diagnosis is necessary since serological analysis for food-specific IgE is not an eVective predictor of actual food allergy—many have food specific IgE in their blood without suVering any allergic reactions associated with consumption of a particular food. Best estimates of reactions are 5–7 per cent of infants and 1–2 per cent of adults. There has been no study to determine eVectively the overall rate of food allergy outside the UK. In the UK the most eVective study has been undertaken for peanut in the Isle of Wight, which was undertaken at two time points several years apart for one food (peanut) in young children. It showed an increase in the sensitisation to peanuts, although there was insuYcient statistical power to determine changes in the prevalence of DBPCFC symptoms. It has been generally assumed that food allergies are following other types of allergic disease (the “atopic march”) but studies (EuroPrevall) have only just begun to define the incidence of food allergy in several countries, including the UK. It may be that exposure to environmental factors (eg indoor environments 50 EAACI; Johansson SG, Bieber T, Dahl R, Friedmann PS, Lanier BQ, Lockey RF, Motala C, Ortega Martell JA, Platts-Mills TA, Ring J, Thien F, Van Cauwenberge P, Williams HC. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organisation, October 2003 ALLERGY(2001),56:813-824. 51 see Bloomfield SF, Stanwell-Smith R, Crevel RW, Pickup J Clin Exp Allergy. 2006; 36(4):402-25 for a recent review. 52 DBPCFC; Standardization of Food Challenges in Patients with Immediate Reactions to Foods. C Bindslev-Jensen, BK Ballmer- Weber, U Bengtsson, C Blanco, C Ebner, J Hourihane, AC Knulst, DA Moneret-Vautrin, K Nekam, B Niggemann, M Osterballe, . Ortolani, J Ring, C Schnopp, T Werfel. ALLERGY (2004), 59:690-697. 53 IgE-mediated food allergy diagnosis: current status and new perspectives Asero R, Ballmer-Weber BK, Beyer K, Conti A, Dubakiene R, Fernandez-Rivas M, HoVmann-Sommergruber K, Lidholm J, Mustakov T, Elberink O, Pumphrey RSH, Stahl Skov P, van Ree R, Vlieg-Boerstra, BJ, Hiller RO. Hourihane J, Kowalski M, Papadopoulos NG, Wal J.-M, Mills ENC, Vieths S, Molecular Nutrition and Food Research 2006 in press. allergy: evidence 287
15 March 2007 aVecting exposure to dust mite allergens, tree and crop pollens, and pollution) together with infections in early life all play a role in the apparent increases in allergic disease in general. However, a cohesive explanation is currently lacking due to our not having an adequate mechanistic explanation as to why some individuals, and not others, develop allergies.
What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 5. Lack of funding for epidemiology studies of suYcient size to define the incidence of food allergies and linking them with other types of allergic disease means we are missing vital objective information on the size of the food allergy problem. Research to provide this information needs to be undertaken in young children, school-age children and adults and backed up with eVective objective diagnosis of allergy with DBPCFC for food allergies. 6. There are no data on the socioeconomic impact of food allergies as the instruments are only just being developed to do this (see above). All that is available is anecdotal information.54 There have been no instruments for assessing the economic impact of food allergies. These are being developed in EuroPrevall but will not be applied in the UK. In order to ascertain the burden of allergic disease the population studies need to be linked to the socioeconomic instruments developed for measuring the disease burden which are available for allergic asthma and other allergies, and now becoming available for food allergies.
Treatment and Management 7. Treatments for inhalant allergies include immunotherapy which is much more widely used in mainland Europe than the UK. This involves administering increasing doses of an allergen and requires considerable commitment from the patient to receive the treatment on a weekly to monthly basis with repeat visits to the clinic. In some instances immunotherapy for inhalant allergies associated with food allergies may aVect the latter. 8. There are currently no eVective treatments for food allergies. Patients with severe symptoms are given emergency medication (adrenaline) and told to avoid problem foods. There may not be adequate resources in hospitals to allow re-testing of individuals to assess if the allergy has resolved, which is especially relevant in children. Without this becoming more routine it is likely that individuals are living with mitigation strategies which are no longer necessary, with all the socioeconomic burden that carries to practice food avoidance. 9. There are potential avenues of research ongoing which may lead to development of eVective preventive measures. Since funding is limited their development is slow. The application of recombinant immunotherapy using proteins resembling allergenic molecules, but with the major IgE-epitopes to de- sensitise individuals, is showing promise for food allergy, including putting in novel delivery vehicles including bacteria. These may, for those individuals with severe reactions, need to be coupled with anti- IgE therapy to avoid adverse reactions to the immunotherapy. There are also potential therapies emerging using parasites, since individuals with parasitic infections do not appear to manifest allergic reactions. Probiotic and prebiotic approaches may act as a preventive by helping to establish a gut micflora that promotes a non-allergic phenotype. These require more eVective intervention studies which also take account of the timing of the intervention. For example, is it only eVective if given in the first months of life when the gut microflora becomes established?
Is the level of UK research into allergy and allergic disease adequate? 10. With regards to food allergy research, the majority of the UK research portfolio is funded by the UK FSA in support of food allergen management. However, FSA does not fund the fundamental mechanistic studies that will be required to develop more eVective diagnostics, therapies and preventive strategies. There is no clear avenue to allow funding of multidisciplinary research regarding the socioeconomic burden of food allergy and to join it up to population studies with individuals with clearly defined food allergies. 54 Miles S, Fordham R, Mills ENC & Mugford M. 2005 A framework for measuring costs to society of IgE-mediated food allergy. Allergy 60 996-1003. 288 allergy: evidence
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Government Policies
11. The information and advice given by governments in general can be confusing and conflicting. This reflects the fact that scientific opinion is not clear and the fact that the research and knowledge that is required to form opinion is currently lacking in two areas: defining the size of the allergy problem (from the number of people with allergies to the cost and burden to society of this disease) and the mechanisms underlying what makes some people become allergic and what makes some substances more allergenic than others.
How effectively are food policy and food labelling regulations responding to the rise in food allergies?
12. The lack of knowledge about food allergies is resulting in policies being implemented which aim to protect the consumer which have not been thought through and are not founded in fact but on assumption. For example, soya has to be labelled as a food allergen and yet studies on soya allergy are diYcult to undertake because of a lack of patients that can be recruited with a defined soya allergy. There is a need also to address how information about food allergies is conveyed to consumers—this has yet to be done. There is a real danger that consumers are being deluged with information but that this is not provided in a targeted and useful way.55 Providing information is not communication. There is a clear need to target information to particular at-risk groups such as young men, who are at greater risk of not managing their food allergies adequately resulting in severe or even fatal reactions. This reflects the risky behaviours this age group may adopt with regard to other health problems. Food allergic teenagers may not carry their adrenaline and read labels in the same way that teenage diabetics do not manage their blood sugar levels. With regard to the industry, allergic consumers are at greatest risk from suVering an allergic reaction whilst eating in a restaurant. These risks would be reduced if there was more support for the development of the tools and materials necessary to promote adequate training on food allergen management in the catering sector. 13. We are not in a position to comment on the two questions posed below.
Are current regulatory arrangements, for example, those governing private clinics offering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory?
Do housing policy and regulations governing the indoor environment pay enough attention to allergy? 6 October 2006
Memorandum by Asthma UK
1. About Asthma UK
1.1 Asthma UK is the charity dedicated to improving the health and well-being of the 5.2 million people in the UK whose lives are aVected by asthma.56 We work together with people with asthma, health professionals and researchers to develop and share expertise to help people increase their understanding and reduce the eVect of asthma on their lives. As the voice of people with asthma, Asthma UK is a proactive organisation that oVers solutions and puts people with asthma first. 1.2 Asthma UK is pleased that the House of Lords Science and Technology Select Committee has decided to investigate issues surrounding allergy in the UK. This is a significant issue for the millions of people aVected by allergies, and presents an evolving challenge for health professionals and government. We welcome the opportunity to share our expertise with the Committee, and would be very pleased to nominate a representative to give oral evidence should this be required. 55 Mills ENC Valovirta E Madsen C Taylor SL Vieths S Anklam E Baumgartner S Koch P Crevel RWR & Frewer L 2004 Information provision for allergic consumers: where are we going with food allergen labelling? Allergy 59 1262-1268. 56 Health Survey for England 2001. Joint Health Surveys Unit, 2003; The Scottish Health Survey 1998. Joint Health Surveys Unit, 2000; Census 2001 (OYce for National Statistics: ONS). allergy: evidence 289
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2. Defining the Problem 2.1 Asthma and allergy are global problems, and prevalence of both in the UK is among the highest in the world, which has been highlighted by several recent studies.57 2.2 Asthma and allergy are very closely interlinked. For the majority of people with asthma, symptoms are brought on through allergic mechanisms. Many common allergens are also common asthma triggers: 90 per cent of people with asthma tell us that their symptoms are triggered by dust and 79 per cent say their symptoms are triggered by pollen.58 Additional allergic conditions including allergic rhinitis, conjunctivitis, eczema and food allergies are also common in people with asthma. Even non-allergic asthma triggers such as cigarette smoke and air pollution can worsen the impact of allergic asthma, and there is much still to be learned about the interplay of diVerent factors in the development of the condition. 2.3 There are significant flaws in our ability to accurately establish the total disease burden of allergy, and particularly allergic asthma. This is in part because of a lack of funding for research in this area. The UK Clinical Research Collaboration reported that research into asthma and other respiratory conditions received a disproportionately low level of funding in relation to the impact of these conditions, which represents a huge barrier to the eVective development of our knowledge base.59 2.4 However, perhaps an even more fundamental reason for our inability to conclusively establish the total burden of allergic disease is that current diagnostic procedures mean that it can remain unidentified. Only 30 per cent of people with asthma tell us that they have been oVered allergy testing to help them to identify what triggers their asthma.60 Skin-prick tests, which can be used to identify allergies, are not widely applied to people with asthma, meaning that the precise allergens that trigger symptoms in allergic asthma are not formally identified or recorded: this can inhibit the quality of treatment as well as preventing us from forming a complete record of the extent of allergy in the UK. 2.5 We estimate that over 12.7 million working days are lost each year as a result of asthma, and that the total annual cost of asthma to the economy is £2.3 billion.61 The high prevalence of allergic asthma means that a significant proportion of this cost is likely to be directly related to allergy, but unfortunately, the lack of allergy testing for people with asthma and the resulting absence of data on the people aVected by it means that precise figures are unavailable. Nevertheless, the total economic impact of asthma and other allergic conditions is likely to be very substantial.
3. Treatment and Management 3.1 As yet it is not clear how to prevent asthma and allergy, but Asthma UK sponsors approximately £3 million of research into asthma every year. Asthma UK has developed a comprehensive research strategy to identify priorities by bringing together the expert knowledge and opinions of people with asthma, researchers, clinicians, the major UK funding agencies, the pharmaceutical industry and the Department of Health. The results of these national consultations provide a framework for the development of Asthma UK’s research programme, which covers basic and clinical research. We are currently supporting 18 research projects specifically relating to allergy, which together represent a financial commitment of £2,470,758. 3.2 In addition, Asthma UK works in partnership with the Medical Research Council to fund the MRC- Asthma UK Centre in Allergic Mechanisms of Asthma, which is a world-class centre of research into allergies and asthma based at Imperial College London and King’s College London. Established in 2005, the centre aims to understand asthma better and to develop new ways of preventing and treating the condition, as well as acting as a training ground for new researchers and as a public voice for new achievements in asthma research. The creation of a centre of this kind provides a unique opportunity to translate basic science findings from the laboratory to healthcare professionals treating people with allergic asthma and will encourage scientists to fast-track the development and testing of new treatments. 57 Prof M Innes Asher MBChB, Stephen Montefort MD, Bengt Bjo¨rkste´n MD, Christopher KW Lai DM, David P Strachan MD, Stephan K Weiland MD and Hywel Williams PhD, the ISAAC Phase Three Study Group. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross- sectional surveys. The Lancet 2006; 368:733-743. Matthew Masoli. Denise Fabian, Shaun Holt, Richard Beasley. Global Burden of Asthma.2002. Royal College of Physicians, Allergy: the unmet need—a blueprint for better patient care, 2003. National allergy strategy group, www.bsaci.org/allergyservices.html, last accessed 26 September 2006. 58 Asthma UK. National Asthma Panel, 2004. 59 The impact of conditions was measured in Disability Adjusted Life Years. UKCRC, UK Health Research Analysis, May 2006: 27. 60 Asthma UK. National Asthma Panel, 2006. 61 Department for Work & Pensions, Information & Analysis Department. OYce of Health Economics. Compendium of Health Statistics, 15th edition 2003–04. Department for Work & Pensions, Information & Analysis Department (April 2004). 290 allergy: evidence
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3.3 It is not certain why the rate of allergy is so high in the developed world, but there are several promising areas of research. For example, there is increasing evidence that infection with gut parasites may protect against asthma and allergy. Asthma UK and the Wellcome Trust are independently funding clinical trials to study the eVects of hookworm in allergy and asthma respectively. 3.4 Also, some studies have suggested that diet may increase a person’s risk of developing asthma and allergies. For example, a recent study funded by Asthma UK showed that children born to mothers who had a low intake of vitamin E during pregnancy were five times more likely to have asthma than children whose mothers had eaten a diet high in vitamin E.62 3.5 There is also clear evidence that infants who contract respiratory syncytial virus (RSV) bronchiolitis are more likely to develop asthma later in life and in severe cases they may also be at greater risk of developing allergies. A number of antiviral therapies are in development for RSV and rhino virus infections that may potentially prevent asthma development.63 3.6 Treatments for allergic asthma are also developing. Recently a novel therapy called Xolair has been developed and licensed for use in people with severe allergic asthma. It is an antibody that binds to and removes the “allergic antibody” Immunoglobulin E (IgE) from the circulation. It is currently being appraised by NICE. 3.7 Also, specific immunotherapy aims to make an allergic person tolerant to the substance causing their allergy by injecting them with increasing doses of the substance they are allergic to until their symptoms are abolished or reduced. However it carries a risk of adverse reaction and trials are underway to administering the treatment in a quick dissolving tablet under the tongue (sub-lingual immunotherapy). This approach looks promising and might provide a new, cost eVective way for people to manage their asthma. 3.8 Nevertheless, the level of spending on research into allergic conditions is far from adequate. This is a substantial barrier to the advancement of our understanding about both the causes and treatment of allergic conditions. The Department of Health’s recent review of allergy services identified a number of significant gaps in research into treatment, particularly in our understanding of eVective models of service delivery and the eVects of patient knowledge on treatment outcomes.64
4. Government Policies 4.1 As well as identifying weaknesses in our understanding of eVective services, the Department of Health’s report illustrated the poor outcomes of current service provision, which can only be remedied by improving policy. There has been a lack of strategic direction, with the result that services are not well integrated and have failed to address the problems associated with allergy. More explicit attention should be paid to allergy and allergic asthma, with better services provided in both primary and secondary care. It is important for the Government to ensure that NICE guidelines on allergy are commissioned as soon as possible in order to help structure future treatment. 4.2 However, improving health is not solely the domain of the Department of Health, and without public health measures across government, the problems associated with allergic asthma will not be resolved. There is work to be done across government and the public sector: in training professionals working with the public to be aware of what to do in an asthma attack, in securing asthma- and allergy-friendly workplaces and in improving indoor and outdoor air quality. 4.3 Poor housing in particular can severely exacerbate asthma symptoms. Damp conditions in particular allow common triggers for allergic asthma such as mould and house-dust mites to thrive. Public health policy and housing policy should be well co-ordinated at all levels of government, and more attention could be paid to the improvement of housing conditions with specific regard to allergy and asthma, particularly in rented accommodation. The consultation on the Code for Sustainable Homes made reference to the use of allergy minimising materials, but it remains unclear whether this will be implemented, or whether it will have any success.65 62 Ref: Devereux G, Turner SW, Craig LC, McNeill G, Martindale S, Harbour PJ, Helms PJ, Seaton A. Low maternal vitamin E intake during pregnancy is associated with asthma in 5-year-old children. Am J Respir Crit Care Med. 2006 Sep 1;I74(5):499-507. Epub 2006 Jun 8. 63 Ref: Henderson J, Hilliard TN, SherriV A, Stalker D, Al Shammari N, Thomas HM. Hospitalization for RSV bronchiolitis before 12 months of age and subsequent asthma, atopy and wheeze: a longitudinal birth cohort study. Pediatr Allergy Immunol. 2005 Aug;16(5):386-92. 64 Department of Health. A review of services for allergy—the epidemiology, demand for and provision of treatment and eVectiveness of clinical interventions. 2006. 65 OYce of the Deputy Prime Minister. Proposal for introducing a Code for Sustainable Homes. 2005. allergy: evidence 291
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5. Patient and Consumer Issues 5.1 The impact of allergies and allergic conditions on quality of life can be enormous. Some allergens are diYcult to avoid, meaning that Many people with allergic asthma are forced to adjust their lifestyles to compensate for this, or live in fear of a severe asthma attack triggered by an allergen. “My quality of life is non-existent. I know this may sound extreme to a lot of people but I would be prepared to lose an arm and a leg if it meant my asthma would go away. I face daily restrictions in every aspect of my life. I can’t go into pubs or clubs because of the smoke, I can’t visit friends because of their pets and people’s cigarette smoke. I also have problems visiting friends for barbecues because the smoke sets oV my asthma. I find it really diYcult to do day-to-day activities on my own—I don’t have enough breath to push a trolley around the supermarket. It’s impossible for me to go to the gym and I’m banned from the local swimming pool as the chlorine and humidity sets oV my asthma. I’m too much of a liability to them. I’m not allowed on an aeroplane and it’s impossible for me to get travel insurance. Winter is also a problem for me—I can’t go outside because the cold air can set oV my asthma.” Suzanne Edwards 5.2 A number of steps can be taken to help ensure; that patients and the public are better informed about allergy and allergic asthma. Improvements in our ability to diagnose allergy would be very beneficial, as would more specialised training for healthcare professionals, and the provision of better-structured allergy services. For example, poor knowledge about allergic conditions often stems from the lack of an integrated and holistic approach to their treatment. People with multiple allergies are forced to see multiple specialists for separate treatments rather than a single allergy specialist, with the result that they are not well informed about their allergies as a whole. 5.3 It is also noteworthy that many people are badly informed about what it means to have an allergy, and about the diVerence between allergy and intolerance. In addition to the development of more robust clinical practices and better-informed health professionals, the production of accessible health promotion materials available in a variety of locations and formats may help to resolve this problem.
6. Conclusions 6.1 Allergy and allergic asthma do not currently receive the priority they should, in either research or services. The problems allergic conditions cause are severe for the individuals aVected and for the national economy. There is a clear need for more research into the basic causes of asthma and allergy, as well as into the clinical eVectiveness of diVerent forms of treatment service to fully develop our understanding of allergic conditions. Yet, even with our current level of knowledge, it is apparent that not enough is being done to treat allergy and allergic asthma. More diagnostic testing is needed, and services across both primary and secondary care stand to be improved. Only then will people with allergic conditions get the treatment they need. October 2006
Memorandum by Allergy UK
Introduction 1. Allergy UK is the operational name of The British Allergy Foundation a charity formed in 1991 to provide information, advice and support to people with all types of allergy/intolerances and their carers. 2. An extensive database of in excess of 80,000 people who have sought help from our charity are registered on our database. In addition to this we also hold a large database of healthcare professionals who have used our services to provide information to their patients and have come to us for educational materials for their own use. 3. We have a dedicated helpline and a growing on-line advisory service and the number of people using the helpline services have increased in the year since March 2005 to April 2006 by 5.37 per cent with 19,554 being received. 4. Helpline callers are supported by our network of “Friends”—volunteers who provide a befriending service which oVers practical non medical advice and a listening ear to suVerers and families under strain due to the impact of allergy on their lives. 292 allergy: evidence
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5. Allergy UK recognising the lack of knowledge also provides education and training to healthcare professionals via Masterclasses and an increasingly popular on-line e-learning European Diploma in Allergy accredited by the University of Greenwich. 6. Allergy UK works in all areas that impact on the lives of allergy suVerers, schools, employment, voluntary groups. We work particularly with manufacturers of products that aim to improve allergen removal/reduction and we are gradually moving into environmental areas such as house building and air quality in the indoor environment of both the home and oYce.
The Problem 7. For the patient the major problem is the lack of knowledge at primary care level. GPs do not recognise allergic symptoms when presented with them due to a lack of training in allergy. This lack of knowledge at best causes distress, at worse can be life threatening, particularly when the GP refuses to refer to an allergy specialist even when the symptoms are clearly beyond being dealt with at primary care level. 8. I list below a few examples of the numerous anecdotal reports we hold of the diYculties experienced by patients: — Mother with young son skin bleeding with eczema—told to just continue with steroid creams, no point in allergy testing as it is a waste of time and money. — 73 year old ate something at son’s house had an anaphylactic shock. Emergency admission to hospital where she suVered three heart attacks. — Hospital A&E wonderful and did everything possible advised referral to allergy specialist. GP refused referral but admitted that another attack would be possible as it was unclear what was the original trigger. — GP told Mother her five year old son was too young for allergy testing but he would like to see the reaction when he was suVering his next anaphylactic shock. — Lady 50s taken to hospital after having diYculty in breathing while out walking—given adrenaline by hospital. GP won’t refer as thinks that it isn’t possible to get allergies in later life. — Child age seven skin sore, eyes covered in eczema and very puVy. Referral refused by GP who says that nothing can be done for the child. — Child aged four diagnosed as being allergic to cows milk. GP advised that the child could drink goats milk instead—result child died. 9. If there is recognition that the symptoms presented could be due to an allergic reaction the GP is frequently unsure of where to refer the patient and frequently will advise the patient to contact Allergy UK for advice on an appropriate clinic. 10. There is a lack of recognition, due to minimal training, within primary care that allergy is a multi-organ disease and GPs will refer a suspected allergic person often to two organ based specialists rather than one referral to an allergy specialist. Very typically this will be a dermatologist and respiratory or Ear Nose and Throat specialist. The result of this double referral often results in additional costs to the NHS and very importantly patients being treated inappropriately with the potential of using more pharmaceutical interventions than might otherwise be needed. 11. The lack of training in allergy and therefore the lack of recognition of patients presenting with allergic disease to the GP means that the reason for a patients visit is usually incorrectly recorded. The lack of correct data means that the problem and level of allergic disease is not properly recognised and this together with the lack of training is the greatest barrier to filling the gaps in establishing the overall burden of the disease. 12. The lack of recognition of allergy also impacts seriously on research into allergic disease. Without properly diagnosed NHS patients there can be no basic research, clinical trials or, importantly, research on NHS service delivery for allergy.
Treatment and Management 13. For people suVering from allergy the recently reported advances in research into allergic disease have oVered a great hope for the future. However the reality of the situation is very quickly realised by suVerers as of little benefit unless: allergy: evidence 293
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— we have trained GPs able to diagnose allergy—if the problem is not recognised how will patients access any new treatments; and — we have allergy specialists able to deliver the new treatments and train Primary Care colleagues in supporting the allergic patients undergoing treatment.
Government Policies 14. Government policy has consistently pushed back the possibility of any progress in dealing with the rise in allergy. 15. The refusal to accept the findings of the House of Commons Health Select Committee and, following the Department of Health review released in July this year, to place the delivery of services for allergy into local responsibility will result in an escalating problem for people with allergy. 16. Allergy UK carried out a survey of PCTs in 2005 regarding their plans for allergy, this clearly showed that PCTs are largely unaware of allergy and generally have no finances available for the service and no plans to improve the situation. We have recently carried out a similar survey which will be released in November 2006 and there is nothing within the new figures which provides any hope for the future in this area. 17. We do not believe that suYcient attention is paid to the quality of the indoor environment in terms of housing policy and regulations. The rise in allergies, particularly those associated with indoor allergens call for greater consideration to be given to the area of building both of homes and oYces. 18. The diYculties for those suVering from food allergies are considerable. It is appreciated that there are severe diYculties for the food industry but unfortunately the “may contain” labelling is now so widely used that it has resulted in increased diYculty in achieving a balanced diet for some people with severe allergies and in some instances suVerers becoming somewhat blase´ about the warning. The Anaphylaxis Campaign have recently launched an initiative, funded by the Food Standards Agency, which hopefully will assist in this very diYcult area.
Patient and Consumer Issues 19. Allergies impact heavily on the quality of life of patients and their families. In a survey of 6,000 suVerers conducted by Allergy UK for its “Stolen Lives” series over 62 per cent of those questioned stated that allergy significantly aVected all aspects of their lives. The diYculties in maintaining the ability to work is very much highlighted by all SuVerers which in turn has a financial impact on the family. Allergy causing poor sleeping patterns results in lack of concentration and energy. This in turn leads to poor levels in the school room with examination results reflecting this. In the work place suVerers are aware of not operating to the best of their ability. Simple things with the family such as outdoor activities, picnics, sports, taking part in social activities are all highlighted as extremely diYcult if not impossible for suVerers. 20. People with allergy rely heavily on the patients organisations for information, services and support. The charities are trusted by the public and we in turn fiercely guard our independence and integrity in delivering our services. 21. The UK is fortunate to have excellent organisations who are dedicated to serving allergy suVerers but all of the services provided by the patients organisations are delivered from charitable funds which are hard won. The expertise within the patients organisations is considerable and with reliable and consistent funding this expertise could be maximised to extend the range and quality of information, advice and support to suVerers and those undiagnosed. 22. As has been highlighted the lack of knowledge in primary care, the inability to obtain proper diagnosis is driving an increasing number of people into undertaking alternative testing. One highly respected paediatrician from a London Hospital stated this week that in the region of 70 per cent of the patients he saw had been told by their GP to go for alternative testing. 23. All of this makes it increasingly urgent that the lack of regulations governing private clinics, diagnostic testing and therapeutic services should be addressed. It is at the present time totally unsatisfactory. Currently there is nothing to guide the consumer on whether the test, clinic or service has been clinically proven in any way. There is nothing to show that the laboratory that is carrying out the testing holds any form of validation. 24. The impact of these alternative companies is considerable on the health and finances of those using them and I give below three examples from our database to demonstrate this: 294 allergy: evidence
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— Mrs S age 32 suVering IBS, Migraine and skin rashes. Visited local health shop for allergy testing. Told allergic to 116 foods and to remove them from her diet. Cost £40 — Mr J age 28 suVering from sneezing, runny nose, cough. Visited iridologist. Told suVering from wheat and dairy allergy And to remove them from diet. Cost £70 — Miss W 58 suVering from headaches, migraine, joint pains, IBS, runny nose and wheezing. Visited private clinic for consultation was admitted and given treatment of what were described as “allergy shots and vitamins” Stay in clinic three weeks, three follow up consultations. Cost £28,000 25. Miss W lost her life savings in seeking a diagnosis and treatment for her problems. This lady and many others have been severely let down by the lack of service for people like her and the lack of guidance on alternative testing and treatment. 26. The anecdotal evidence that we have gathered highlights the seriousness of the situation which will only get worse unless something is done about the lack of allergy services within the NHS.
General 27. Allergy UK are extremely concerned for the future given that a sizeable number of the few allergy specialists there are in this country are due to retire within the next five years. 28. Unless funding is directed into allergy services allowing education and training to be addressed particularly at Primary Care, the excellent research which is currently taking place will never translate into actual treatment for the majority of allergy suVerers in the UK. 7 October 2006
Examination of Witnesses Witnesses: Dr Glenis Scadding, Consultant Allergist, Royal National Throat, Nose and Ear Hospital, Dr Clare Mills, Head, Structuring Food for Health programme, Institute of Food Research, Ms Donna Covey, Chief Executive, Asthma UK, and Ms Lindsey McManus, Deputy Information Manager, Allergy UK, examined.
Q777 Chairman: Thank you for coming today to Ms McManus: Right across the board from: Where is give evidence. I have met some of you before. I am my nearest allergy clinic? Where do I get allergy Baroness Finlay and I chair this Committee. We have testing carried out? What type of test might I expect a list of our declared interests which is published so when I go to the hospital? Could I have an allergy? we will not be running through all of those today. They might phone up with symptoms and we can Could I ask you to introduce yourselves? only point them in the right direction.66 We are not Dr Scadding: I am Dr Glenis Scadding. I am an NHS medically qualified, but we can give practical advice consultant allergist working at the Royal National on allergy management. They may have been Throat, Nose and Ear Hospital in London. diagnosed already and want help on how to avoid Dr Mills: I am Dr Clare Mills. I am a biochemist and certain allergens and we oVer very practical advice I work at the Institute of Food Research in Norwich such as bedding and cleaning. We can also give advice which is a not for profit research institute funded by on diVerent types of tests and alternative testing, the BBSRC. should they ask us. Ms Covey: I am Donna Covey. I am the chief executive of Asthma UK. Q779 Chairman: Do you provide advice on those Ms McManus: I am Lindsey McManus. I am the types of tests? deputy information manager at the charity, Allergy Ms McManus: We cannot provide advice on tests that UK. we do not believe have undergone any clinical trials. We would not be happy to do that. We do tend to direct them straight to their GP if they have not been there. Q778 Chairman: Can I ask what are the most 66 If callers are enquiring after an NHS clinic we would give details common questions from members of the public who of the British Society of Allergy and Clinical Immunology phone Asthma UK and Allergy UK helplines? BSACI. allergy: evidence 295
15 March 2007 Dr Glenis Scadding, Dr Clare Mills, Ms Donna Covey and Ms Lindsey McManus
Ms Covey: At Asthma UK we have a nurse run advice Ms Covey: Firstly, it is diagnosis. In terms of the line which takes telephone calls and also answers e- baseline diagnosis, it still takes the average person mails and letters. They take anything between 7,000 seven trips to a doctor before they get to a diagnosis and 10,000 queries a year and we monitor those. of asthma. On top of that, we are still very poor in the About 30 per cent of calls to our advice line are UK at diagnosing when the asthma is allergic and from people experiencing symptoms, either a new when it is not. Our data shows that only 30 per cent symptom of their asthma or a worsening symptom. of people with asthma are referred for any sort of Just over 20 per cent are about medication. People allergy test by their GP. Most people do not even find it diYcult to get good advice about asthma know whether their asthma is allergic or non-allergic, medication and a lot of those queries are about side which then means that even starting a conversation eVects. About 5 per cent of our callers are newly about how you self-manage, how you avoid the diagnosed and it is the, “Hello, I have asthma; what triggers, becomes almost impossible. There is does that mean?” call. About 3 per cent are on the secondly the next level about what sets the condition indoor environment. About 3 per cent are about oV, what is likely to be causing it. There is also an complementary therapies and about 3 per cent are issue about people needing much more information product queries. The rest are a mish-mash of various themselves, knowing what their asthma is triggered things. That is basically how our calls to the by, how to understand when their asthma is being Adviceline pan out. triggered and self-management. We know that self- management plans, for example, in asthma make a V Q780 Chairman: Do your organisations work with huge di erence in terms of hospital admissions, days V others such as the National Eczema Society and the o work and quality of life; yet fewer than one in five Anaphylaxis Campaign to support allergy patients? people in the UK with asthma have a personal Ms McManus: Yes. asthma action plan even though the British Thoracic Ms Covey: Yes, we do. We run holidays called Kick Society guidelines make it very clear that this can V Asthma holidays. We used to run something called really make a di erence and recognise the Asthma PEAK holidays which we ran jointly with the UK plan as a gold standard. It is about information National Eczema Society because so many children and understanding and also about people around with asthma also have eczema. We make the Kick you understanding, things like perfume, for example. Asthma holidays available to children with eczema That can be a huge trigger to people’s asthma. One of and a lot of the work we do on those holidays with the the things that we do a lot of work on in Asthma UK children is about them getting used to their asthma is just getting the real world to understand small and their allergies. We try to make things like food things like not having heavy perfume in buildings and allergies easier. Instead of it being awful when they thinking twice before animals are wandering around V had to go in front of the whole class and say, “I all over the place. Those can make a huge di erence cannot eat this and I cannot eat that”, at the start of to people in terms of the management of their the weekend everyone does it. “Who does not eat asthma. The other issue with asthma is second hand shellfish? Who does not eat peanuts?” It normalises it smoke which is one of the biggest triggers to people’s and an understanding of allergy is a really important asthma and we welcome the role the Lords are part of that work because with conditions like playing in ensuring that we are going to have a smoke asthma people do not always understand. It is not free UK. just about the medical symptoms. It is about how Chairman: Thank you so much for that last comment asthma impacts on your daily life and things like in which I will bask. eating. If people go into a restaurant and order they take it for granted. For people with asthma and other Q782 Baroness Perry of Southwark: The Charity allergic problems that is such a loaded thing all the Commission published a report last month. I think it time. was called Stand and Deliver: the future for charities providing public services. They highlighted that many Q781 Chairman: What would you identify as the charities were not really being paid the full cost for largest gaps in the management of allergic diseases at the services they deliver to patients. To what extent home, at school, at work and out in society? do allergy charities provide patient care activities? Ms McManus: Initial diagnosis is the first stumbling What does that mean for patients and how does it block. A lot of people self-diagnose and that is quite impact on the funding they receive? a worry. We need advice there for these people when Ms McManus: As a patient information charity, we they need it right from the very first step. We would do not have an awful lot of outside activities for like to see more education at the primary care level, patients but we provide a nationwide network of particularly for GPs and practice nurses, right the support contacts so that people with allergies are not way through to pharmacists. out there on their own. They can be in contact other 296 allergy: evidence
15 March 2007 Dr Glenis Scadding, Dr Clare Mills, Ms Donna Covey and Ms Lindsey McManus suVerers. Obviously it is not medical advice but they to an hour on a call. A GP has seven minutes to talk can give support. We do become very much a to somebody and listen to them when they have listening ear. Often our calls are quite lengthy in asthma. He has to diagnose and prescribe at the same supporting these people. If they have just been time whilst doing that. Whilst we are not in the trap diagnosed, they are very frightened. If a child has just of people who provide services and do not get paid been diagnosed with a peanut allergy, the mum is their full costs, we are in a diVerent trap where what absolutely terrified. She does not know what to do or we are doing is promoting best practice and we are where to go so it is listening and giving them the time not being paid for it at all. We know what we do that is so important. We do provide a lot of transforms people’s lives and in some cases can save education. We are about to start an expert patient lives. We produce something called an asthma attack course later this year which is going to be totally card which people can carry with them. It tells online and it will be for the likes of parents, suVerers, somebody else what to do when someone is having an playgroup leaders and Scout leaders so that they can asthma attack. About 80 per cent of people with get a better understanding of what allergy is. Most severe asthma cannot ask for help when they have an people do not understand the basics of an allergic asthma attack because they cannot speak. Every time reaction. It takes away the fear and helps them we advertise that using voluntary funds we get V manage better. We also o er a bereavement inundated with calls. Two years ago when we first counselling service for those who have lost members launched it we had to get a new phone system at our of their families to allergy. national oYce. At Asthma UK we feel quite passionate about the service we provide and the Q783 Baroness Perry of Southwark: My question failure of government to take up these issues. was about the funding. Dr Mills: In terms of food allergies, the Anaphylaxis Ms Covey: This is a huge issue for Asthma UK Campaign worked very hard to train anaphylactics in because we provide a number of what are really NHS the use of adrenalin pens and that is crucial. A lot of plus services. They complement what the health their work is funded from donations and corporate service does in terms of individuals but also working donations and I am not sure that they have any other directly with the NHS. That includes our Adviceline funding for that work. which is staVed entirely by nurses, all of whom have an asthma qualification on top of their normal nursing qualifications. There are our Kick Asthma Q784 Baroness Perry of Southwark: Staying with the holidays for children. There is our provision of health Department of Health system of contracting and promotion material, including things like self- funding, will that put allergy charities in competition management plans which are something used jointly with each other, do you think, or will it foster by the health care professional and the person with mergers? What will the eVect be on patients of all asthma to manage their asthma. We also work with that? local primary care trusts, particularly in areas with Ms McManus: It could possibly foster mergers. We high asthma morbidity in terms of funding pilot all work hand in hand with each other anyway. We projects in diVerent areas to try and work out how we can move asthma care forward. At the moment we do tend to keep in touch so that we know what is going all of that from voluntary income, not government on, but at Allergy UK we do not get any funding funds. We do get caught in this Catch 22 situation. from outside apart from donations. When we apply for government funding for our Ms Covey: In the allergy sector we do not have that Adviceline, we get turned down on the grounds that multiplicity of charities that you see in some other it overlaps with NHS Direct. It does not. NHS Direct sectors. For example, Asthma UK is the only nurses quite rightly often refer people with asthma to national organisation that solely does asthma, our nurses who can have a detailed chat about their although others do a bit of asthma as part of what asthma. Similarly, we have been turned down before they do. We do work closely together. We do not by with regard to our health promotion materials on the and large duplicate each other’s work. If there were grounds that asthma self-management promotion is to be more government money available for the job of the NHS and yet we know large parts of the providing more advice, information and services to health service do that really badly and when they do people with the full range of allergic conditions, I it well it is because they are using our materials. That am sure that there is such a huge gap that we would is an outstanding issue for organisations like us who all manage to work together to work with the have been doing stuV for a long time so we do not Department of Health and health care providers to qualify for new money that you get for doing new and fill that gap. The real problem is at the moment that shiny stuV. We feel what we do complements what nobody is trying to fill the gap except us and we are the NHS does. For example, our nurses will spend up doing it from voluntary income. allergy: evidence 297
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Q785 Baroness Perry of Southwark: Do you think it Dr Mills: I agree with what has been said already. would have an eVect on patients if there were better collaboration and more mergers perhaps? Ms McManus: They are already getting a pretty good Q788 Baroness Platt of Writtle: You will probably service anyway. We give the best advice we possibly say no, but are GPs adequately educated to deal can. We all spend an awful lot of time on the phone with allergic diseases and, if not—this is the key and we almost provide a counselling service for question—how can this situation be rectified? these people. Dr Scadding: GPs are not adequately trained to deal Ms Covey: Unlike some areas of health care, asthma, with allergic diseases. In medical schools the amount respiratory and allergy are areas where the charities of allergy training is absolutely minute, if it exists at work really closely with health care professionals. I all. GPs are sent out into the world ignorant of know that is not always the case in some areas with allergy. The British Society of Allergy and Clinical the health care bodies. Our area is a model of how we Immunology are trying very hard to improve GP can work together in terms of how the charities work training by joining with an organisation called the together and have their own areas of expertise. Also, Primary Care Allergy Network. We are trying to give we work very closely, for example, with people like guidelines to GPs. We are making very detailed, the British Thoracic Society, the GP in Airways evidence based guidelines and producing a primary Group. I know you took evidence from Professor version. We are trying to organise how a GP in an Tak Lee earlier on in these sessions about the work he eight minute consultation could sort out whether a does, running the centre that we run jointly with problem is likely to be allergic and, if so, where the the Medical Research Council. I would hope that best secondary treatment should be sought. We are patients do benefit but they would benefit by having trying to do it on the basis of our specialist society but more money to spend. I think we get the best of both it needs doing on a UK-wide basis and it should be worlds at the moment because we have a good level Department of Health funded. of specialisation. For us as an asthma charity, not everyone’s asthma is allergic so by being asthma specialists we are able to handle the asthma specific Q789 Viscount Simon: I was wondering what advice issues and refer people on. If we were to lose that we Allergy UK oVers to patients or callers who claim would lose a lot. For us, the “Tescoisation” of the to suVer from multiple chemical sensitivity or charity sector would not necessarily be a good thing. environmental disease. Ms McManus: One of the biggest problems is that we Q786 Baroness Platt of Writtle: If a person thinks find, by the time people call us, they are quite they may have an allergy, who would you advise desperate. There is very little knowledge of the them to consult in the first instance? condition and people become quite depressed and Ms McManus: It always has to be their GP. very isolated with the condition and the way it has Unfortunately, because of the lack of training for developed, because they are reacting to things in the GPs, their allergy knowledge is often quite limited. environment. A lot of professional health advisors do Often patients get referred on to the wrong person so not believe that is possible, so they become labelled. it might be a gastroenterologist or a respiratory Obviously, because we are not medically qualified, physician when they really need an allergist. Allergy we have to check whether there is an underlying is a multi-organ disease. If you can get them to an medical condition there, so we do always check that allergist to start with, it is quite important as they they have been to their GP for other tests to make may have eczema or asthma or rhinitis and an sure there is not something else wrong there. If there allergist can sort that out for them. However, it does is not, we can give advice on how to avoid chemicals have to be a GP first and foremost because they have within the home environment, how to avoid a to refer them. chemical load on their body if that is the kind of Dr Scadding: I would like to criticise what Andrew information that they are looking for. We can give Dillon said. The statement that “most allergies are support because often they become very isolated competently managed in primary care by generalists” from their family and in their workplace. We have is absolutely wrong. Some diseases which have an advisers on our health advisory panel who are very allergy component are dealt with in primary care by knowledgeable on chemical sensitivity. If there is generalists with pharmaceutical medications like nowhere else we do pass them on to the British topical corticosteroids. The allergies underlying them Society for Ecological Medicine where they can get are not looked for and this is a very big mistake. expert advice.
Q787 Chairman: Dr Mills, do you want to comment? Q790 Viscount Simon: Do you get many callers? 298 allergy: evidence
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Ms McManus: Yes, a lot and we are getting more Q793 Lord Colwyn: We had a discussion about unfortunately.67 pharmacists in the previous session. I wonder whether any of you want to add to what Helen Young said when we discussed whether the department were getting the correct advice from pharmacists about Q791 Lord Colwyn: Could all of you say what you which allergy treatments to use and when they should feel about the use of neutralisation/provocation use them? tests? Are they supported by Allergy UK and all of Ms Covey: I would quite like to put in a plug for you? pharmacists certainly with regard to asthma. We Ms McManus: It is one of these tests that have not have just done some work at Asthma UK with the undergone trials so we cannot support them. There Pharmaceutical Services Negotiating Committee as a are other tests that we would not pooh-pooh because result of which we have produced a joint pack around a lot of people do seem to find benefit from them, but medicine use reviews on asthma because we feel that you have to be very careful when you are deciding for some people, particularly with follow-on advice, what clinics you go to. Many of these treatments are the pharmacist is a good place to go if it is done done privately which is a big worry. properly for people who live with a condition all their Dr Scadding: I did a paper 20 years ago trying to life and do not want to go back to a GP every five disprove this. I was very cross about this kind of minutes. The pharmacist is a real resource and we technique. In a very small study it looked as though have had 10,000 of those packs ordered already there might be something in very low dose, sublingual by local pharmacists. Obviously at the moment desensitisation. I got so much flack from the allergy pharmacy advice is still patchy but we see a real community at that time that I largely stopped doing it willingness amongst certainly the trade bodies but now sublingual immunotherapy is accepted and in pharmacy to work much more closely with there is a Cochrane meta-analysis of high dose organisations like ourselves on some of these issues. immunotherapy. If you look at the ALK data on We are hopeful that in future there will be much more GRAZAX there is the beginning of a curve and it scope for pharmacists providing advice so that may well be that there is an eVect of low doses. I think people can get advice in a much wider range of places this needs proper scientific investigation in good when it suits them. One of the problems is that, hands on a double blind basis. This will be because people do not always like to go to their somewhere to spend some experimental money. doctor, they let things drag on and they get slowly Dr Mills: I would endorse that. It is quite important worse. They do not want to go to their GP unless it is to understand this. In a study that was done in the really bad and it is half a day oV work. Quite often, Netherlands looking at desensitisation to pollen, the the pharmacist can be a fantastic stop-oV point for individuals lost their pollen allergy but they did begin people in that situation. The PSNC have done this to develop an allergy to apple, which is related. This work with Asthma UK around these issues in asthma is why immunotherapy is a very complicated therapy and we are having a huge take-up already from local and it does not get rid of people’s allergies. It stops pharmacists so I think that is really part of the way them perhaps expressing some of their symptoms and forward. there may be quite complex interactions with some allergies disappearing and others reappearing. Q794 Chairman: You said 10,000 packs. How many individual pharmacies are there in the UK? Does that represent 10 per cent, 20 per cent or 50 per cent? Q792 Chairman: What was your response to the Dr Scadding: I think there are around 40,000. answer we had from Mr Dillon from NICE? Dr Scadding: I was a little shocked that NICE is not Q795 Lord Colwyn: Would a pharmacist be allowed prepared to look at sublingual immunotherapy or at to supply an adrenalin pen? immunotherapy in general because it can cure Dr Scadding: Not without a prescription. In the field allergic disease and it is the only hope of curing it at of rhinitis, which is my special area of interest, the moment. Corticosteroids are pretty eVective but pharmacists have been given ARIA in the pharmacy, they do not cure the disease and it is a long term the guidelines on Allergic Rhinitis Impact on treatment. I think the government and NICE should Asthma, which are very simple and very good. The take the long view about funding. It may be that BSACI for a couple of years running sent down a immunotherapy is expensive in the short term but if single A4 sheet of the best treatments for hay fever it can give long term results then it is a long term cost- which did go to all 40,000 pharmacies in the UK. eVective measure. Given that kind of advice, pharmacies are a 67 There is nowhere on the NHS that suVerers can get help, and it wonderful resource, but they should not be used to is not recognised by the medical profession as a whole. diagnose allergy. allergy: evidence 299
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Q796 Lord Soulsby of SwaVham Prior: Iam aligned with all those things, more information both detecting a much more positive attitude to for doctors and patients so that it is available in immunotherapy from you ladies than we have heard practice and the right people get it in the right way in previously from other witnesses. Maybe you heard the right place and at the right time. earlier that we found when we went to Germany, for example, that immunotherapy was quite popular. Q798 Lord Soulsby of SwaVham Prior: Where would Could I bluntly ask you, should it be more widely one put the pressure to get NICE to look into it in a used in this country? more positive way? Dr Scadding: Yes. I think probably it should be used Dr Scadding: I suspect directly on NICE, if possible. very much earlier in this country. At the moment it is Could I say that I think it is an absolute nonsense that reserved for patients failing on pharmacotherapy. NICE is looking at omalizumab, which is a very However, if you look at what happens in Europe expensive treatment. It does not cure, it needs to be there is a study looking at children with rhinitis taken long term, it is not particularly eVective in treated by immunotherapy and now after 10 years severe asthma and they are considering that and they are 2.5 times less likely to have asthma than a failing to consider immunotherapy which is a more cohort of children of a similar age treated with drugs. eVective treatment and can be curative. That progression from rhinitis to asthma, which we see to have a threefold relative risk, can be almost Q799 Chairman: Going back to the diagnostic end completely ablated by immunotherapy. of this, do you think that there is adequate regulation Dr Mills: I think it is also worth saying that for private clinics and the procedures which they oVer sublingual therapy oVers a much better route for for allergy diagnosis and treatment, and how can the administration than having the kind of conventional patients choose who they should go to if they are injections at frequent intervals, it makes it much going to a private service rather than going through more realistic to use. their GP? Ms McManus: I do not think people realise the Ms McManus: I think this is a very diYcult question. impact of something like allergic rhinitis or hayfever A lot of these private clinics are not regulated and on people’s lives. They think that hayfever is quite a you only have to look on the Internet to see the minor condition, but it can impact dreadfully, amount of diVerent forms of allergy treatments that particularly on children who are just about to sit their are popping up, some of them are very, very strange exams right at the height of the hayfever season. that you have never heard of. Some things should There has been research carried out that they do not cause great concern like NLP, neurolinguistic do as well in their exams as they did in their mocks programming, where, theoretically, psychologically earlier in the year, so it is very important. you can cure an allergy. How you decide which one is good I do not know. We tend to give NHS clinics Q797 Lord Soulsby of SwaVham Prior: We could because we know that they are going to be looked take from you that we should include in our report a after there, but there is just not enough of them, positive statement that immunotherapy is something unfortunately. this country should embrace a bit more? Ms Covey: I think aligned with the point that it is very Q800 Chairman: Dr Mills? important, as people have said, that we have more Dr Mills: The British Society of Allergy and Clinical information so that people are able to work out what Immunology has a list of people and that is where I is the best thing to do, what is the lowest risk thing to point people to because I feel that is a trusted list of do. Also, like Glenis, I was sorry to hear what accredited people who know what they are doing. Andrew Dillon said earlier because really until the Dr Scadding: I agree. Anyone can set up as an Department of Health and NICE start moving issues allergist and it should simply not be allowed, we like this up the agenda then we are never really going should have some kind of proper accreditation with to see a move forward, so it is not just about it being a recognised qualification. more widely available in theory, it is about it being more widely available in practice, having proper Q801 Chairman: Are there false claims being made guidelines and also a strong message that it is a over allergy treatments? priority. The reality is that in busy general practices, Dr Scadding: Yes. in terms of referrals and how people understand things, GPs are focusing on the things they are being Q802 Lord Colwyn: I think we covered this subject in told are a priority, essentially either because it has the earlier questioning and it is about the University financial incentives for the practice attached to it or of York study that was commissioned by Allergy they are expected in order to get the right number of UK. Is there anything you want to add to that? You stars to do it. It would have to be wider availability probably heard our discussion. 300 allergy: evidence
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Ms McManus: I think Dr Hart covered it very Q805 Lord Colwyn: Of course the number of experts adequately. The study that we commissioned was on are so few and far between, inevitably you are going over 5,000 people and of those who stuck to it rigidly, to be using tests. which was something like 67 per cent, I believe, 75 per Dr Scadding: Absolutely, people and training. A lot cent found a huge improvement in their condition. of primary care nurses are being trained in doing skin Dr Scadding: It is well known that irritable bowel prick tests and interpreting them in places like the syndrome can respond to dietary exclusion, I have no Respiratory Training Centre at the Athenaeum in dispute with that. What I do dispute is that it is worth Warwick and I think that may be a way forward. making any attempt to identify IgG antibodies, we all Dr Mills: I would just like to endorse what Glenis has make IgG antibodies to food. Dr Pamela Ewan will said and for food allergy it is even worse. There are a tell you that 100 per cent of the population she studies lot of people who will have apparently been sensitised had IgG antibodies to egg and I see no way in which to foods like wheat but do not have any symptoms, this can be used to guide diet. In the Gut paper, which and that can be really problematic when people is the best paper produced, the sham group did not eliminate important food groups from their diet. avoid dairy or wheat, which are the two major problems with IBS patients, and, therefore, it is not Q806 Chairman: What about the issue of surprising that at the end of the study there was a 10 inflammatory bowel disease that we heard about in per cent diVerence. In that paper the number needed the last evidence session? to treat was nine, whereas if you do an exclusion diet Dr Mills: In terms of the IgG? the number needed to treat is somewhere between two and 2.5, so I do not think there is any point in Q807 Chairman: Yes. spending money on IgG antibody tests, you are Dr Mills: It is not particularly my area of expertise, better oV going to see a dietician and using an but I think that it is a symptom in that people do exclusion diet followed by re-introduction. The IgG benefit from dietary interventions, but the link at a antibody tests are liable to leave patients on diets that molecular basis between IgG and irritable bowel are inadequate and patients often like to think they syndrome is not apparent and we make these are improving and they carry on in the teeth of very antibodies to our food protein as part of our normal little improvement and may end up malnourished. functioning.
Q808 Chairman: Ms McManus, this was a study Q803 Lord Colwyn: Are these self-testing kits you that, if I am right, your organisation commissioned. are referring to? I wonder if you have anything that you want to add Dr Scadding: No, this the York Laboratories blood to what has been said? testing. Ms McManus: The main thing that I have to say is it is because of a lack of NHS services, we have nowhere else to send these people to. We would give the York Q804 Lord Colwyn: Tell us what you think about test purely because it is the only one that has Y self-testing kits and are they su ciently regulated? undergone clinical trials, particularly for IBS, and Dr Scadding: They should be banned. I am very sorry, that is why we are happy to endorse it for those kinds but I saw a child this morning before coming here. of symptoms, but we would not recommend any We did skin tests, which are well recognised, and she other test. had skin tests to house dust mite and also to tree pollens. She has absolutely no symptoms referable to Q809 Baroness Perry of Southwark: A question for the tree pollen whatsoever, she does not have spring Dr Mills really. What role does the Institute of Food hayfever, she has good symptoms related to the Research play in the primary prevention of allergic house dust mite, so I treated her with house dust mite disease? avoidance and immunoallergy therapy. If she had got Dr Mills: I have been thinking about how to answer a kit then she would have felt that she was tree pollen this one. If you see preventing allergic disease in two allergic as well and something had to happen about parts, the first part is preventing somebody becoming that. She has sensitisation but not clinical disease, allergic, how do we stop people even producing IgE. and if you do a test only about half the people with At a fundamental level we still really do not that positive test will have clinical disease, so you understand the mechanism whereby one person cannot have self-testing kits, they are going to lead to becomes allergic and another one does not, we really misdiagnosis, wrong-allergen avoidance. You need do not at a very fundamental level, and that is where both the test and a detailed history taken by the IFR has a role because we have a lot of the somebody who has some experience of allergies to be BBSRC-funded research on a fundamental level of making an interpretation of tests. what are the molecular mechanisms underlying that allergy: evidence 301
15 March 2007 Dr Glenis Scadding, Dr Clare Mills, Ms Donna Covey and Ms Lindsey McManus and, particularly, there is the dialogue between the Q812 Lord Colwyn: We heard from Gideon Lack gut bacteria and the human host in early years from the hospital over the road about the work he is understanding that at a molecular level. I think that is doing. I imagine it will not be long before you identify fundamental in designing preventative strategies that the cause of the allergy in the peanut and then really work in an incontrovertible way. That is one genetically modify it? level. The other level is somebody who gets allergic Dr Mills: Some people have already started doing and how do you prevent them from getting an allergic that. One of the diYculties is that there are quite a lot disease. We have heard about immunotherapy and of proteins in the peanut that cause allergy and if you one of the things that we are developing is possible remove them by genetic engineering you will not have oral vaccination strategies using engineered lactic a peanut any more, it will be something else. acid bacteria, but there is another level related to my Dr Scadding: I was going to mention Gideon Lack’s own personal research which is understanding the work of feeding peanuts early to babies but you allergens in foods and how they trigger allergic already know about it. reactions to food. That is very important when you start looking at doing allergenic risk assessments of Q813 Baroness Perry of Southwark: Yes, indeed, novel foods, you do not want to introduce a novel thank you. Apart from food avoidance, are there food that is going to cause problems, like peanut, and any other eVective treatments which can be how do you do that. That is part of the role, for recommended for people with food allergies? example, I have in putting into the advisory Dr Mills: Not at the moment. committee on novel foods and processes which do that. The IFR provides lots of fundamental research which underpins that. The other thing we have is a Q814 Baroness Perry of Southwark: Really? big database that we set up with EU funding which Dr Mills: If you have got food allergy you spend your has a lot of information about foods that people are life reading labels. My other plea is really if we are allergic to and I think providing them with that going to address these issues and get to the bottom of information is where we see us working hand in hand them, we need some joined-up thinking with the with the allergic consumers. fundamental science, the biological science and the clinic, but we also need the social science. In the work we have done in EUROPREVAL, my EU project Q810 Baroness Perry of Southwark: Following on with economists, we have shown in preliminary evidence that in the families which have to live from that, do you think it is appropriate that the with food allergies it is women who bear a current government advice still recommends the disproportionate burden of the cost because they are avoidance of peanuts for babies who have a family the carers and have significantly lower socio- history of allergies? economic status. They miss a lot of work because of Dr Mills: That was founded on research that was hospital appointments and so on, so there is a big done some years ago and I think an awful lot has economic burden. I think that is a given for allergy as happened since then. a whole and is part of the equation in saying, “Well, okay, immunotherapy may not be perfect but it is going to give a benefit to quite a lot of people”. It Q811 Baroness Perry of Southwark: Exactly. might cost more, but if you have somebody who is 14 Dr Mills: I suspect the Food Standards Agency, and they are going to have that for the rest of their which is particularly involved in some of that, is life, that is a long time for somebody to have to suVer probably wanting to go back and re-examine it, that burden of disease and we need to do some sums particularly in the light of the recent studies where in which incorporate that. the USA they have been introducing peanut in an eVort to desensitise; clearly, that has to be done under Q815 Baroness Perry of Southwark: Of course it is clinical supervision because you do not want a child expensive to the economy anyway because they have to have an adverse reaction. I am involved in this big time oV work. European study and we also work with people from Dr Mills: But we do not have the numbers which back around the world and in Ghana, where they eat a lot that up. of peanuts, they introduce peanuts as a weaning food in subsistence farming and eat peanuts as a very large amount of the diet. I think understanding how the Q816 Baroness Perry of Southwark: What do you exposure aspects aVect allergy there are lots of think the Government should do to educate patients lessons we can learn from other communities around about their food allergies or intolerance for those the world I think to help prevent that in the future. with true allergy about emergency medication? 302 allergy: evidence
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Dr Mills: We did some work quite a few years ago from where I sit as a lay person. We are keen to see looking at this, and trust is a very important part of more work into the role of infection in producing giving people information. There are two groups that allergic inflammation, the relationship between are pivotal in all of this. The first is the clinic, the infection and allergy. Also we need to see more clinician and the doctor, and the second is the allergic research into immunology, which we have already patient groups. Those are two providers of talked about, and new treatments for allergy, information that are very, very important and I think including the potential vaccines we have for allergy. I they should be supported in doing that. I see us as think in the long term what we really want to see is a fundamental science institute providing that allergy taken much more seriously and much more information in a form which allergic consumers can research on these issues so we can start to understand use to pass on to their membership. what the real answers are going forward, not just to enable them to live with allergic conditions but also Q817 Baroness Perry of Southwark: We heard to reduce the amount of allergic conditions in the UK evidence from Dr Jean Monro who said she could going forward because it is an epidemic and it is a treat food allergy with sublingual therapy, even for growing epidemic. peanut allergy. What do you say to that, particularly Dr Mills: I have already said I think we need to Dr Scadding? have better joined-up and a greater proportion of Dr Scadding: I think we need proper trials of fundamental research into the biology because the sublingual immunotherapy. There are reports from clinicians are not going to get the answers that we the American Academy of Allergy and Immunology need, they have a diVerent role to play. on the sheer sublingual desensitisation to hazelnut, so Dr Scadding: I think we need to look at primary it may be a possibility, but it needs to be properly prevention: whether we can mimic bringing up done in a very carefully-controlled setting. children on a Bavarian farm with something like Dr Mills: I think the options for that may also be endotoxin; whether something else like vitamin D is more viable for those people who suVer nut allergies playing a role is an interesting idea from America, which are associated with pollen allergies and that is that lack of vitamin D may be relevant since this helps a much more realistic therapy for food allergy as to regulate T-cells; whether secondary prevention opposed to the people who are just allergic to nuts. is possible; whether we can switch oV with immunotherapy early on in the course of disease, V Q818 Chairman: Leaving aside the need to improve switching o rhinitis and preventing the downward allergy services, I wonder if you would agree that is slide into more complex allergies; and I think the link number one to improving allergy services but, if we with infection is very important. If we could cure the put that on the side, what are the most important common cold we could prevent an awful lot of exacerbations of asthma, sinusitis and otitis media areas that now need to be addressed to improve the V services for patients generally in terms of prevention, with e usion. Then, finally, there is a possibility that treatment, research and so on? bacterial infection may be a complicating factor Ms McManus: I think for Allergy UK it is education. of many allergies, we see it with polyps, atopic dermatitis and asthma and whether by then it is too late to do anything about the allergy because there is Q819 Chairman: Of? the secondary problem of a chronic bacterial Ms McManus: Primary care, local GPs and practice presence and a diVerent kind of T-cell infiltrate. nurses. They are the first port of call. Ms Covey: For us there is a real issue about research. Asthma UK funds a fair amount of research into Q820 Chairman: I wonder if I could ask you, Dr asthma generally and also the allergic mechanism of Scadding, how often do you see patients whose asthma but really it should not just be left to a charity treatment has been inappropriate? I am not talking through voluntary donations to be trying to move about the ones where the allergic element has this debate forward. Our Basic Asthma Research been missed but where they have been treated Strategy identified a number of priorities and that is inappropriately for their allergy and, therefore, have how we bring together a whole tranche of diVerent come to clinical harm before they are referred? scientists, clinicians and other experts to try and say, Dr Scadding: At least once a week and often more “Well, if we have to focus on asthma research what than that. should we do?” That identified a number of areas that were allergy-explicit, in particular the whole issues Q821 Chairman: What are the main causes? around how allergy and allergic asthma develop. Dr Scadding: The main causes are that they have been There are things like the hygiene hypothesis that unrecognised and under-treated or treated for people still cannot agree on, but if we could get to the something other than allergy. bottom of it it might be a really useful way forward Chairman: Thank you. allergy: evidence 303
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Q822 Lord Colwyn: Not being a great fan of Dr Scadding: No. antibiotics, would you suggest, in fact, treating Chairman: Could I thank you very much for having people with colds with antibiotics to prevent further come today and giving us evidence so clearly. If there infection? is anything else you would like to submit we will look at it as part of the evidence from today. Thank you all.
Supplementary memorandum by Allergy UK
This evidence addresses issues raised in the oral evidence session of 15 March 2007 which it was not possible to fully explore within the session. Thank you for sending through the transcript of the minutes of evidence taken before the House of Lords Science and Technology Sub-Committee. Q796 Allergy UK would like to pick up a statement made by Dr Glenis Scadding that Pharmacists should not diagnose allergy. It is the belief of Allergy UK that the majority of allergy could be successfully diagnosed and managed in primary care and this includes, as an essential part, Community Pharmacists. We believe that given the correct training there is absolutely no reason why Pharmacists could not play a major part in meeting the desperate need of people with allergy to know and understand what is causing their allergic symptoms. We appreciate that in an ideal world everyone presenting with allergic symptoms would be seen by an allergy specialist, we are however realistic that this is not going to ever be possible given the lack of specialist training posts in allergy and the present thinking of health services being delivered at primary care level rather than secondary care settings. We have therefore carefully considered the needs of primary care and as stated in evidence the greatest need is for education of OP’s and Practice Nurses and we also believe in education to maximise the tremendous skills and knowledge available in local pharmacies. Q809 Allergy UK would also like some clarification placed before the Sub-Committee regarding the York Test. As the Lords were made aware by Lindsey McManus this is the one test that we endorse. The test, as was made plain, has undergone clinical trails at Manchester Hospital and this coupled with our own anecdotal survey led us to look in more depth at the service and advice given by York Test. In her evidence Dr Scadding states that it is better for patients to see a Dietitian and nobody would dispute this, however our extensive experience has shown that being able to obtain a referral to a Dietitian who understands food intolerance is extremely diYcult on the NHS. I think it is important for members of the Sub-Committee to be aware that in addition to the clinical trial and the anecdotal studies, we also assured ourselves of the service level to their clients by York Test. In addition to the test, York Test clients have the opportunity (usually taken up) for two consultations with a Nutritionist/ Dietitian. They receive an excellent guide to their condition and the advice is very clear that they should not continue on an exclusion diet beyond the stated period of time. We have yet to receive a complaint from anyone who has undertaken the York Test and in fact have many calls from people stating that it has revolutionised their life and given them back their quality of life. Q785 Allergy UK would like to echo Donna Covey’s comments that the advice services of both our Helpline and Information often falls between two stalls. We are in fact doing the work of the NHS, in providing advice, support, information for the general public and we are educating healthcare professionals, all from our funding which is generated outside of statutory funding. It is extremely diYcult for charities such as Allergy UK to generate funds from a totally unbiased source of income. We regard it as vital to do so to guarantee “best advice” is given. As Donna Covey stated we are often rejected for funding on the basis that we are providing what should be a statutory service and in other areas we are often rejected for funding because the service is well established and is not “a new project”. Our materials are used extensively by healthcare professionals as is our advisory service, yet we do not receive funding to guarantee the production of these materials and their ongoing reviews. 21 March 2007 304 allergy: evidence
WEDNESDAY 18 APRIL 2007
Present Broers, L May of Oxford, L Colwyn, L Perry of Southwark, B Finlay of Llandaff, B Platt of Writtle, B (Chairman) Selborne, E Haskel, L Soulsby of Swaffham Prior, L
Examination of Witnesses Witnesses: Mr Ivan Lewis, a Member of the House of Commons, Parliamentary Under Secretary of State for Care Services, Mr Alan Bell, Project Lead, Allergy Services Review and Mr John Bromley, Head of National Service Reviews, Department of Health, examined.
Q823 Chairman: Good morning. Thank you for recommended that the health agenda should be coming. Could I welcome you, Under Secretary of considered across all government departments when State, and also Mr Bell and Mr Bromley for coming developing policies. Can you explain to us how you today. I am Lady Finlay; I am chairing this Sub- work with other departments, particularly in relation Committee on Allergy. This is being web cast and we to the needs of allergy patients and how these needs will be going round asking questions. There is a are taken into account? Members’ note of declared interests so we will not Mr Lewis: I think essentially, if the NHS is to move run through those prior to any questions because it is from what it has been, eVectively a sickness service, all there and will be published. Could I ask you if you to a health service, the reality check for all of us is that would formally like to introduce yourselves for the there are a whole variety of factors which impact on record, and then we will go into our questions? people’s health and well-being, many of which are Mr Lewis: Thank you very much Lady Finlay. I am not within the controls solely of the Department of delighted to have the opportunity of appearing Health, so it is absolutely essential that we make a before the Select Committee. I am Minister for Care reality of the rhetoric around joined-up government. Services in the Department of Health. Essentially I Anybody who has been anywhere near government have two sets of responsibilities: one is for children’s knows that it is one of the more challenging tasks that health and the other is adult social care. I think we we face because joined-up working is not the same as would all agree that allergies are a massively sitting around the same table at Cabinet Committees, important issue for the many, many families that are frankly: it requires a far more integrated and aVected by them and it is an issue which perhaps has profound way of looking at diVerent policy areas not had suYcient priority or profile, historically, but than that. I can give a specific range of examples of the impact that allergies can have on the entire family how, relevant to this issue, we are trying to work in a is quite serious indeed. So I personally think we have more corporate way. First of all, at ministerial level, quite a long way to go in terms of, first of all, giving there is a Domestic AVairs Cabinet sub-committee this issue the priority status that perhaps it deserves, on public health. That is underpinned by a supportive but also in the way that we diagnose allergies and also structure at oYcial level of programme boards, obviously both health and social care response to including the Health Improvement Board. So families experiencing this particular condition. I will essentially you have a ministerial oversight of a leave it at that in terms of opening remarks. number of groups of oYcials working on specific programmes and policies. In terms of our work with Q824 Chairman: Thank you. Mr Bell? other government departments on a bilateral basis, if Mr Bell: Good morning, I am Alan Bell; we have met you like, which is relevant to the focus of our before. I am at the Department of Health and I discussion today, we are working very closely with led the recent review of allergy services by the Defra on air quality issues. Defra chairs an Air Department. Quality Interdepartmental Group, which meets every Mr Bromley: My name is John Bromley. I am the couple of months, and there is an Air Quality Forum Head of National Service Reviews, so I look at all at which brings together other stakeholders from the clinical reviews in the Department of Health. outside of government as well as the relevant government departments. In 2005 we issued joint Q825 Chairman: Could I ask you the first question guidance with the DfES on Managing Medicines in and start oV by asking you about the government Schools and Early Years Settings, and that includes departments and how they work together. The specific guidance on anaphylaxis, which obviously is Council for Science and Technology Report on a welcome and important step forward. We “Health Impacts—A Strategy Across Government” obviously have to work very closely with the Health allergy: evidence 305
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley and Safety Executive to exchange information on funding be coordinated through an OYce for occupational allergies, and in terms of looking at our Strategic Coordination of Health Research. Can you policies on indoor air quality we did work closely tell us how you would expect this to impact upon the with the Department for Communities and Local level and allocation of funding for allergy research? Government and they also worked with us in terms Mr Lewis: Obviously we first of all have to consider of their proposals for ventilation rates as part of the properly Cooksey’s recommendations. The interim Building Regulations. In terms of children and young oversight group for the OYce for the Strategic people, obviously there is a Minister for Children, Coordination of Health Research was only which is a very, very important step forward. There is established in January, and it is at the moment the Every Child Matters strategy, which seeks, more discussing the detail of how the recommendations than anything, to demonstrate the case for the made by the Cooksey Review will be taken forward. earliest conceivable intervention with children and That OYce for the Strategic Coordination of Health young people, whether it be through the NHS or Research will be working with UK health whether it be through the education system in formal departments and the OYce of Science and childcare. Certainly the Every Child Matters agenda Innovation to define our health research strategy seeks to bring all government departments together going forward, and that will include the strategic to look holistically at the needs of children and direction for research into particular disease areas. families, starting from the beginning of a woman’s To be very frank with you, at this stage I cannot tell pregnancy and all the way through to the beginning you the level of financial commitment that will trigger of primary school and then beyond. So I think there over the next few years—as much as anything else, as have been advances in terms of interdepartmental Members of the Committee will be aware, the and cross-government working, but I personally Comprehensive Spending Review deliberations are think—not just on this issue but on a whole range of not concluded—so in terms of being absolutely clear issues—that if the big picture challenge is to secure about the level of government resource that will be the health and well-being of local populations it is available in this area at this stage it is not possible for no longer enough simply to regard that as the me to say that. Would I hope that, by having the responsibility of the Department of Health or Cooksey recommendations and the new structure Primary Care Trusts at a local level; there really has that will be created as a consequence of Cooksey’s to be a joined-up approach. My own view is there recommendations, it will lead to a higher priority needs to be a much closer relationship between PCTs, being given to allergies and a clearer focus? Clearly I local government and the voluntary sector in every believe that that will be the case but I cannot give you community and we need to move away from a woolly a tangible commitment on how much additional notion of partnership to a more hard-edged notion of resource this may trigger. a genuinely integrated joined-up approach. Mr Bromley: One thing I would like to say is that we in the Department spent quite a lot of time to try and Q826 Chairman: Could you just explain why allergy get the organisation up to speed as quickly as comes under your remit as care services? Is it just possible, so that it could make a bid as part of the because it has been lumped on you or is there a CSR 2007. So it has made a bid and I think that bodes V specific area of activity? well for the future. E ectively it is a question of Mr Lewis: I think I would be in serious trouble if I timescale but we wanted to get the organisation up described it as having had it lumped on me. As I said and running so that it could do that. at the beginning, my responsibilities are clear—they are children’s health and social care. If you looked at Q828 Earl of Selborne: The case that Sir David the other Ministers’ responsibilities it would not Cooksey made very persuasively, I felt, for bringing necessarily be simple to decide where responsibility together this OYce for Strategic Coordination was for allergies would belong in terms of any one the mismatch between some of the basic work done Y Minister’s responsibility. I think it is a di cult call to very eVectively by the Medical Research Council and make, if I am frank, because it covers acute NHS the inability to get this translated into clinical care, primary care, social care, and with kids it has research. Given that the MRC has funded such work relevance, so there is a whole range of policy areas. I as molecular mechanisms of allergy, and at the other think it could sit with several members of the end of the spectrum there is this great need to get this ministerial teams—public health—so why it is with translated into clinical research, where would you me—and, as I say, I will not use the word “lumped” expect the emphasis to change if the OYce for on me—I am not totally certain. Strategic Coordination gets into its stride? Mr Lewis: I think we would want obviously better Q827 Earl of Selborne: The Cooksey Review has coordination; we would want a clearer strategy going recommended that the Medical Research Council forward because I think if you look at the history it funding and the National Health Service research has not been particularly impressive and I think that 306 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley is why Cooksey’s report was so important. So more always been as good as it needs to be and that the focus, greater priority, clearer focus on the outcomes health research strategy that we have published will we are seeking to achieve. I think the Committee will make a real diVerence in that respect. be aware that £4.75 million has been allocated over five years to the National Institute for Health Q830 Lord May of Oxford: More specifically, the Research, specifically to look at allergy. I would hope clinical research by its nature is linked to allergy that essentially it would lead to more resource but a services, so precisely how will the OSCHR clearer focus on allergy as an issue in terms of coordinate this kind of research when the allergy research in this country. services themselves are being commissioned locally Mr Bell: If I may briefly add to that as well. by individual Primary Health Care Trusts? The Committee will be aware that one of the Mr Lewis: The link between practice and research is recommendations of the Cooksey Review was to obviously one you will be far more aware of than establish a Translational Medicine Board to work myself, but it is absolutely clear. What we have is nine jointly between the new National Institute for Health organisations now, essentially Strategic Health Research and the Medical Research Council, to give Authorities, and the PCTs in every locality are a strategic direction for translational research within responsible to those Strategic Health Authorities, the context of the overall health research strategy. and it would seem to me that there is an opportunity That is something that we certainly propose to take there in terms of perhaps one of the Strategic Health forward once we have OSCHR itself up and running Authorities taking lead responsibility and being a properly. conduit in terms of making sure that in what is happening there is a link, there is a direct correlation Q829 Lord May of Oxford: My question sort of between research and practice at a local level. It relates to this but a particular aspect of it, in that would be a nonsense to suggest—I am not sure how clinical allergy research often involves long-term many Primary Care Trusts there are these days—that prospective studies that require funding over many there could be a realistic or credible relationship at years and a lot of it is not in the elegantly precise, sexy Primary Care Trust level and research, but I think imagery of molecular biology where you can do nice, certainly Strategic Health Authorities, which are clean precise things. So there are two kinds of organised on a regional basis, would also of course— tensions: one the long-term and one the fact that it and maybe we ought to make more of this—have does not fit some people’s image of what is the best coterminosity with Regional Development Agencies, kind of basic research. When you couple that which also obviously have a role to play in terms of together with the disconnection that the Cooksey research. So I think that may be a model that we need report seeks to address between our excellence in to explore as a Department and maybe one option, as clinical research and perhaps in a global league table I say, would be to get one of the Strategic Health positioning near the top in delivery of healthcare, I Authorities to take lead responsibility. wanted to ask how do you see the new arrangements aVecting for the better funding for these kinds of Q831 Lord May of Oxford: One other follow-up long-term prospective studies? question, of a more technical kind too, is that it has Mr Lewis: I think we would say that Best Research been suggested to us by some of the people we have for Best Health, which is obviously the new strategy, talked with that it would be extremely useful if there is all about ensuring stability in terms of research was a coordinated central disease registry that held funding. We think it also opens up the possibility of details, in so far as they are available, of allergy sustained funding specifically for high quality patients’ genotypes, phenotypes and responses research proposals, epidemiological studies and to various types of treatments as a unified and clinical trials. We think that that strategy oVers a coordinated whole. What is the Department’s view significant new opportunity. I suppose an example of on this? that is the resource that has been allocated that I Mr Lewis: My initial response to you is that I do not referred to earlier over the five-year period. There is have a view. the NIHR, which also provides a key mechanism through which the Department of Health will deliver Q832 Lord May of Oxford: I would have thought the new research and development strategy. So I your initial response might be it would be a bloody think there is a framework now which gives us an good idea! opportunity to create a longer-term, more stable Mr Lewis: I am not sure. You always have to look at approach, but in the end we will be judged by the whether the infrastructure that we need to create to diVerence that that makes and at this stage that new ensure that we have that database—I do not think my framework, that new strategy is at a very early stage oYcial agrees with you that it would be a bloody in its conception. I think we would say that what has good idea, by the way, judging by the note just passed happened to date has not been satisfactory, has not to me! I am sorry, you are not supposed to say words allergy: evidence 307
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley like that in such august surroundings! The reality is reporting theme and the expectation is that that will that I will go away and reflect on that and consider provide additional data and in particular—and I whether the benefits really do bring the added value think this will help with evidence—certificated that would be necessary in terms of the cost in sickness absence. The HSE, as Lord Haskel is investing in the infrastructure. If the cost brings real probably aware, has recently published a report on added value and real benefits then it is something that the costs, in their view, of asthma. The Memorandum we ought to look at, absolutely. But I think the case for the Committee included some specific examples is not proven. of how the Department and HSE work together—I am not going to at this stage report those. What is the Q833 Chairman: Does Mr Bell want to comment in true cost? There is no doubt that the cost burden of the light of this note? new cases falls most heavily on the individual worker Mr Bell: I think I had better now! I was simply going and society. The report that was published estimates to suggest, as I think the Minister has really, that this that total lifetime cost to society of new cases of is an issue that does come up quite frequently across occupational asthma diagnosed in 2003 was ranging a range of diseases and it is always going to be a case from around £71.7 to £100.1 million, and if of weighing the benefits against the costs, which can comparable numbers of new cases were diagnosed in be quite considerable. future years this would give rise to additional streams of lifetime costs of similar magnitude. So that is an attempt to respond. Q834 Lord May of Oxford: There is a huge comparative advantage we potentially have with the NHS, which is not exploited nearly as eVectively as many of us think it could be. Mr Lewis: Can I suggest, to help the Committee, that Q836 Lord Haskel: Thank you. You did refer to the we write specifically on that issue because that will database, and when we saw Professor Agius, who mean we will go away and give it some very serious runs The Health and Occupation Reporting network thought? at Manchester, he told us that he thought that this Chairman: Thank you, because there are, I think, 150 database was under threat. Has the Department of PCTs across the country, which is why this link Health discussed the importance of data capture with between research and translation in clinical practice the Health and Safety Executive and will funding be becomes important. Lord Haskel. guaranteed for this project, for this database in the future? He was obviously concerned that funding was V Q835 Lord Haskel: Could we turn to the eVect of going to be cut o . allergy on the economy, and can you tell us what Mr Lewis: Lord Haskel will be well aware of this kind steps you are taking with the Health and Safety of advice—it says it would be unhelpful for me to Executive to know the true number of people comment. But of course my responsibilities to a suVering from occupational allergic disorders, and as Committee of the House allow me to say that. As I well tell us about the types of jobs most commonly understand it, there are ongoing contractual aVected? And can you deduce from that the cost to negotiations, so the question is, is there a question the nation’s economy? mark over this and the answer is yes—that is the Mr Lewis: A bit of a tall order, but we can certainly logical conclusion of there being contractual talk through the work that we do with the Health discussions and contractual negotiations. So to be and Safety Executive. We exchange information very frank with you, until those are resolved we are on occupational allergies, and we have joint not clear about what is going to happen going membership of Committees and direct involvement forward, but that is the truth of the position. of NHS physicians in some of the Health and Safety Executive’s activities. The HSE uses a number of sources to obtain information about the number of people suVering from occupational allergic disorders Q837 Chairman: Could I just ask, it would be helpful and their jobs. I think those are outlined in the for us to have an update as well after this session Memorandum that we submitted to the Committee. because it was on 10 January that we had evidence There is a particular database, which is The Health and Professor Agius in that evidence commented that and Occupation Reporting network, which records the funding had finished at the end of the month and new cases of occupational allergic disease referred to they are carrying out schemes partly through reserves consultant level, and the details in that respect of funds and partly through charitable support, and include the case’s occupation, the industry they work that was back in January. So if we could have that in in and the suspected causative agent. I believe that writing afterwards? recently the Health and Safety Executive has also Mr Bromley: I will make sure you get an update as commissioned an occupational health trained GP quickly as possible. 308 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley
Mr Lewis: This is the THOR scheme? if they act immunologically and the primary intended purpose is to test for an allergic reaction. However, Q838 Chairman: Yes. to date—and this may change—the MHRA has Mr Lewis: As I understand it, the funding is 2004 to received no applications at this stage for market 2008 and the option in terms of the contract that was approval. agreed was whether beyond 2008 we would go to 2012, so I would be surprised if there was an Q842 Chairman: Does the government have any immediate funding problem. input into the raising awareness days, such as the Bad Hand Day, which the Hairdressers’ Association Q839 Chairman: It would be really helpful then to is running, or is that organised completely have it clarified for the Committee. independently by their own association on their own Mr Bromley: We will write to you. initiative? Mr Lewis: I am not aware at this stage that the Q840 Chairman: We know that the prevalence of government has any involvement in it. hair dye allergy as an occupational problem, and Mr Bromley: I think it is through the DTI and I think indeed for consumers, is increasing and the there is some kind of sponsorship. Once again, I can Scientific Committee on Consumer Products in find out, but I am sure that there is government March produced a memorandum, following which sponsorship in the relevant department for that. the European Commission announced that it will extend its assessment of hair dye products. We also Q843 Chairman: And it would be helpful to know know that there are cross-problems with black, semi- the amount of sponsorship when you are permanent tattoos. Can you tell us who is responsible investigating that. for ensuring that allergenic chemicals in these Mr Bell: I would add that the other government body products are properly labelled in the UK and what with an interest as far as hairdressers go is of course the government is doing to make sure that the public the Health and Safety Executive and that body are aware of the potential risks when using these has produced written guidance specifically for products? hairdressers. Mr Lewis: I certainly never expected my ministerial Chairman: But a lot of these products are not sold brief to take in hair dye! But it a serious issue actually, and used by hairdressers, they are used at home. And an increasingly serious issue. tattoos certainly are not done by hairdressers; but that is another area. Lord Soulsby. Q841 Chairman: It is. Mr Lewis: You also mentioned the question of Q844 Lord Soulsby of SwaVham Prior: The next tattoos and that, again, raises all sorts of very, very question is somewhat related to the previous one. significant health issues that maybe we would not From previous evidence we have heard that the have been responding to only a few years ago. I think terms “hypoallergenic” and “dermatologically there are diVerent levels of responsibility here, so it tested” are meaningless. The question is how will the would be helpful to go through those. First of all, the government ensure that consumers are protected manufacturers of cosmetic products, including hair from misleading claims placed on cosmetics, bed dyes, sold in our country are responsible for ensuring linen and other products? that their products comply with something called the Mr Lewis: There is first of all the general. Any Cosmetic Product (Safety) Regulations 2004, as description of a product by a manufacturer or a amended. Those Regulations were designed to vendor must not be false or misleading, and this also implement the EU Directive on the safety of applies to labelling, whether provided voluntarily or cosmetics, for which the Department of Trade required by regulation. So, in general, there must not and Industry is the enforcing authority, and on be false or misleading information or labelling. There their behalf it is Local Authority Trading is action that can be taken, if that were to happen, Standards Departments that are responsible for under the Trade Descriptions Act of 1968: it is a implementation on the ground. Amongst the criminal oVence for a person in the course of a obligations under these Regulations are strict business to apply a false or misleading trade labelling requirements in terms of making consumers description to goods. Enforcement of the Act again is aware—all cosmetic products must be marked with a the responsibility of Local Authority Trading full listing of the product’s ingredients, including Standards services. There is also a new Directive— colouring agents. In actual practice, the testing for the Unfair Commercial Practices Directive, adopted allergy to hair dyes is commonly carried out by using on 11 May 2005, which will, as a consequence of a small sample of the dye on the skin; tests sold Regulations, take eVect in April 2008, where the separately to test hair for adverse reactions prior to Department of Trade and Industry is the lead dyeing can be considered to be a licensable medicine, department. What that will do is to introduce a allergy: evidence 309
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley general prohibition of unfair commercial practices by Mr Lewis: They certainly have a code of practice, traders towards consumers; it will also help to they certainly have parameters, yes, and there are strengthen consumer protection against unfair selling rules—there are codes of practice. I cannot say today and marketing methods as well as scams, obviously. whether they have even looked at this issue—I Among the practices specifically prohibited—and I suspect that they have not—but there is absolutely no think this is the bit that is the strengthening—are reason why we could not refer this matter to them false claims that a product is able to cure illnesses, and seek information from them—the Committee dysfunction or malformations. “Hypoallergenic” is a could do it but we could do it as well—and get them medicinal claim and, if made for a medicine, would to focus their attention on whether this is a serious have to be supported by clinical data before it was problem in terms of advertising and whether there are given a marketing authorisation by the MHRA. So I potential breaches of their code of conduct. It seems think that the Unfair Commercial Practices Directive to me that the question triggers an action from both is an opportunity to toughen and to strengthen the us and the Committee, which could only be helpful. regulation and the legislation which covers this area. I think the other issue, frankly, is enforcement. In an Q847 Lord May of Oxford: I may have area as technical as this it is hard to believe that Local misunderstood something here—and I do not think Authority Trading Standards OYcers are marching we should spend too much more time on it—I around local retailers looking for this, and it may well thought you just said from the pending legislation be that it is something to which we would want to give that it said “hypoallergenic” is a medical term, some thought, to ask Trading Standards OYcers and whereas the spirit of the question that is being asked Local Authorities whether they could do a piece of is we have heard people say it is gobbledygook, that work around these issues. is to say it is not so much misleading as meaningless, but misleading by trying to sound like it means something. Q845 Lord Soulsby of SwaVham Prior: Do I Mr Lewis: Yes, and that is the problem legally understand from your answer that you think because if a member of the public were to view it as that there are standards set already really in the incomprehensible that is not the same as it being various areas and that basically it is a question of misleading or inaccurate. enforcement, or have I misunderstood you and that Lord May of Oxford: You read a form of words more needs to be done? a moment ago which suggests that the pending Mr Lewis: I am not a lawyer; I am sure there are legislation defined, gave it meaning, which is going to lawyers perhaps on the Committee. I suspect that on be complicated for us if we get to say anything about the issue of misleading consumers, one of the this. We should look at it in detail later. diYculties is that that would have to be tested in the court, so you would have to look at the language that is used; you would have to have enough confidence Q848 Chairman: We do not want to spend too much that, essentially, it was misleading. But then, having time on it but, actually, talking about something hypoallergenic should mean that it has a low done that, if you decided to take that further you potential to trigger allergy and cause an allergic would have to then, obviously, test it in the court and response, but it does not mean that it is non—it is the ultimate decision by the court would demonstrate hypoallergenic—and I am not sure that we have to us, first of all, whether the Trade Descriptions Act really seen claims for particularly non allergenic covers this area adequately, but also from April 2008 attached to substances for which there is no known whether the Unfair Commercial Practices Directive allergy anyway, such as water. has further strengthened the regulatory and legal Mr Lewis: I have to say I think this reinforces the framework that aVects this issue. So I think it is a point. I suspect that there are two issues here. One is question of enforcement, it is a question of being whether the manufacturers believe that the new legal confident that there is suYcient evidence to take the framework requires them to change the language matter further, and I guess it would be a significant they are using because their lawyers will clearly have test case in this area, and then it would be for the to make judgments about that; secondly, whether judgment of a court. ultimately in this area there would be a test case, in my view. Q846 Lord Haskel: One of the problems about Chairman: I think I would like to move away from these claims is that they are made in adverts, they are cosmetics, if we can. Lady Platt. not often made at point of sale; so the Trading Standards OYcers are at a disadvantage. Perhaps the Q849 Baroness Platt of Writtle: This does change the Advertising Standards Authority also would have a subject. The House of Commons Environment say in this. Are they aVected in this way by the Unfair Committee’s report on “Indoor Pollution” Commercial Practices Directive as well? recommended at that time that the government 310 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley clarify and simplify the departmental responsibilities Mr Lewis: I cannot answer that at this stage; I can for indoor air quality. Who is now responsible for write to the Committee if that would be helpful. We ensuring a healthy atmosphere inside buildings and know that the Air Quality Forum, which may or may who should be educating the public about the not be the same body that you are referring to, does management of dampness, house dust mites and still meet because it met on 22 March and it seems to mould? I might add, is the Interdepartmental Liaison be the body that took responsibility for considering Group on indoor air quality still operating and what the best way of clarifying roles and responsibilities, work does it carry out? but I do not know if you are referring to that body or Mr Lewis: I think we accept that responsibility in adiVerent body? this area remains across a series of government Baroness Platt of Writtle: Perhaps you could clarify it departments, and we have to do something about afterwards. that. There was a meeting only on 22 March of Chairman: We understood that there was another the Defra Air Quality Forum, which met then body as well. Lady Perry. specifically to look at the scope for clarifying and simplifying these responsibilities. So the government Q851 Baroness Perry of Southwark: Minister, we acknowledges that there is a need to clarify but that were very interested in a recent development in has not yet been done and I think the work of this Scotland where Fairfield Housing Cooperative has Committee will, frankly, help the government—and built 14 aVordable low allergy homes. These used I am sure you will want to do that—to clear up non-toxic materials, they avoided the use of gas responsibility in this area. The primary responsibility heating and they incorporated various heat recovery for ensuring a healthy atmosphere inside buildings and ventilation strategies. Have you discussed with is shared between ourselves and the Department other departments whether the construction industry for Communities and Local Government. That should use more of these strategies when building department is responsible for the Building new houses? How could you encourage that? Regulations system for England and Wales; that Mr Lewis: As I understand it, the Department for includes setting standards for ventilation in new Communities and Local Government oVered some buildings and those that are undergoing material funding specifically for the design and monitoring of change of use. The purpose of ventilation is to draw the Fairfield development. As a consequence of that, fresh air from outside into the building to dilute guidance has now been produced on the subject to pollutants and so to maintain good air quality inside. guide others who would want to go down this path, There are many hundreds of airborne chemical but that would be on a voluntary basis. I think the compounds inside buildings and the eVects on health question here really is how active government is of only a few are well understood. The Department going to be in saying that the Fairfield development of Health’s Committee on the Medical EVects of Air produced evidence which is highly persuasive and Pollutants provided guidance on the eVects on health desirable in terms of other types of development, and I suspect at the moment it is simply by having of indoor pollutants in 2004 and that report guidance that is available; that is quite a passive suggested maximum levels for selective pollutants. position to adopt. Whether we ought to be more The Department for Communities and Local proactive is something we ought to reflect on. Again, Government used that information to set ventilation what I can oVer to do following this evidence is standards in the Building Regulations, to control, as to write to the appropriate colleague in that far as possible, those pollutants. The Regulations are department, flagging up this issue, raising the not tailored to the needs of individual occupants, but question of Fairfield and the persuasive evidence that individuals are not precluded from improving their Fairfield oVers, and ask them to consider what more indoor air quality by using all sorts of means—filters, they can do, rather than simply issuing guidance, to dehumidifiers, et cetera. Also, the Department of get future developments to look at the Fairfield Health and the Health Protection Agency provide model. advice on the impact on health of indoor air pollution. So it is true to say that there are lead Q852 Lord Haskel: What is more, it would be departments that would have a greater focus on this putting it into the Building Regulations. than others, but there is still a need to clarify roles and Mr Lewis: Absolutely. The Building Regulations are responsibilities across government and that work is uniform at the moment, they are not focused on ongoing at the moment. distinct needs. But absolutely, that ultimately would change behaviour.
Q850 Baroness Platt of Writtle: Does this Q853 Baroness Perry of Southwark: As I understand Interdepartmental Liaison Group on Air Quality it, Minister, this particular project produced houses still operate? which were not only low cost but which were healthy allergy: evidence 311
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley in lots of other ways as well, so it would go broader done by the Food Standards Agency—those were than simply being allergy proof. only published recently and I do not know if the Mr Lewis: I agree. Committee has sight of them? It would be worth the Committee having sight of them. The outcome of Q854 Chairman: And they were energy eYcient as those two research projects was published in March well. and April of this year so they are very, very Mr Lewis: I was just going to say that, in terms of contemporary. We are going to need to seek the view what is happening next, the DTI is consulting at of the independent expert committee, which is still the moment on a new strategy for sustainable established, on the findings in terms of the Food construction, and it seems to me that there would be Standards Agency’s research. Having done that we another opportunity to influence what will come out will then consider whether the existing advice needs of that because if they are going to publish a new updating, refreshing or completely changing, but we strategy in the near future it would be logical, if need to consider what that advice tells us. Would it Fairfield is as persuasive as it appears, to have that as help the Committee if I were to be a little more part of the new Strategy. So I will write to colleagues specific about essentially some of the key elements of in both those departments if that would be helpful? the advice that we currently give to people?
Q855 Chairman: Yes, it would. Q857 Chairman: Yes, it would. Mr Lewis: And flag this up and when we get the Mr Lewis: Pregnant women who are atopic (which response we will forward that to the Committee. some members of the Committee will be aware, is an Mr Bromley: I would say that as a department we inherited tendency to develop allergies) or for whom are having discussions with the trade bodies, the father or any sibling of the unborn child has an the Construction Confederation and the National atopic disease, may wish to avoid eating peanuts and Federation of Builders as well on this issue, so we are peanut products during pregnancy and breast being proactive on that and looking at these forms of feeding. Those same mothers are also recommended V construction and how they a ect people’s health. I to avoid introducing peanuts into the diet of their think there are other trade bodies as well that we need children until their children are three years of age. to contact, but we have started the process. For mothers from non-atopic backgrounds, the Government advice is not to introduce peanuts into Q856 Lord Colwyn: I am afraid we are coming at an infant’s diet before six months of age, and then you from all angles and this is a total change of only crushed or flaked to avoid choking hazards. subject, about pregnant mums and young children Whole peanuts should not be introduced until five and advice that is given to them. We have been in years of age. We can laugh at this because for some Denmark recently where the National Board of parents this is commonsense but for other parents Health specifically does not issue dietary avoidance they would simply be unaware of some of these guidance for mums and infants because they say issues. there is not adequate evidence to support the claim Lord Colwyn: But, Minister, we are becoming aware that this prevents allergy development. On the other that that advice is not correct. hand, we are also aware of studies that show that levels of vitamin D in mothers-to-be have a pronounced eVect on the chances of their children Q858 Lord May of Oxford: It may be irresponsible, developing a condition, and lack of vitamin D, found indeed. in oily fishes, et cetera, can hinder the development of Mr Lewis: Hold on, that is very serious. Our position a child’s lungs and immune system. We know about at the moment is that there is no definitive evidence the importance of selenium and zinc. Can you tell us to support this advice, which was based on possible who is responsible for updating the Department of mechamisms identified in 1998, which is why this Health’s dietary advice and then perhaps after that I research is really quite important. could be a little more specific and ask you what Chairman: We visited the research unit at St. specific advice you are giving on peanut consumption Thomas’ where there is a big study going on, and they and maybe avoidance for pregnant mums. were suggesting that it may actually be making the Mr Lewis: Hairdressers and peanuts, there is an situation worse to avoid peanuts during pregnancy interesting combination! The current advice that we and to delay exposure to any peanut products. The make available, which is described as precautionary, position with whole nuts is completely diVerent, that is based on a report that was issued by an is about choking and not about allergy, and we have independent expert committee, the Committee on to be very clear that we separate whole nuts that can Toxicity, in 1998. There have been two research block oV the windpipe of a baby from the allergy projects which have been undertaken to actually potential. But there was concern expressed to us consider the impact of that advice, and that has been during that visit—and they have a large research 312 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley project going on—and that concern was echoed when mothers, particularly with their first baby, during we were in Denmark. establishing breastfeeding and that there is a Baroness Perry of Southwark: I think we were also tendency still in this country, more than in others, to told, if I may, Lord Chairman, that in countries default to formula simply when the women have not where they wean babies on crushed peanuts there was had enough support to establish breastfeeding, and it no peanut allergy, if there is very early exposure to becomes particularly important for those who have peanuts. atopy. Mr Lewis: I think what we have to do is look at all Q859 Chairman: That was particularly from Israel of the content of the current advice with the and from African countries where they are often independent body that initiated it the first place, weaned on to groundnut soup. which still exists. I think we have to take account of Mr Lewis: Looking at the research that has just been the FSA’s research on the impact. But we should also published, which has considered the impact of the utilise international evidence; and if it is evidence advice that is out there, what that has indicated is that rather than simply judgment or perspective then we the advice is misunderstood—that is their take on ought to take account of that, and if it is persuasive this—in that many non-atopic mothers also avoid we have to ensure that that influences our advice. peanuts during pregnancy and breastfeeding. There was no clear eVect seen in either study on the Q862 Lord Broers: This brings us back again to prevalence of peanut allergy in the United Kingdom. labelling, having been around the houses, as it They have looked at the impact of the advice that is were. Evidence has shown that the ubiquitous use out there, and that is their conclusion in this of defensive allergy warnings on food labels information that has been published only within the unnecessarily limits the range of products allergy last few weeks. suVerers can buy. How will you work with the Food Mr Bromley: I would say that the FSA is close to Standards Agency to ensure that information agreeing a contract to conduct mechanistic research regarding allergens is made more accurate, or should based on the clinical study that you have talked I say suYciently numeric, when the EU reviews its about, so we are involved in looking at that. food labelling legislation this year? Mr Lewis: This is quite serious. Mr Lewis: The FSA acts on behalf of the government in this area and we will expect them to ensure that our Q860 Chairman: Yes, it is serious. views on this are taken very, very seriously as part of Mr Lewis: It seems to me that if people are the European Union review. Having spent a lot of misunderstanding the advice that is one issue but if time in the EU when I was a Treasury Minister I the advice is entirely wrong and counterproductive certainly cannot guarantee the outcome, but I can and actually damaging people then we really need to assure the Committee that we will be seeking to move rather quickly, rather than having ongoing influence this review so we end up with the outcome incessant reviews. So what I will commit to do is to that we desire. Would it be helpful to give you some get the research that has been published, have a very update on what they have recently done on this issue intensive look at that in the next few weeks and then because the European Commission has actually come back to the Committee, having drawn some made some changes in this area recently? conclusions about what we need to do next. But if we continually set up reviews it seems to me that we have Q863 Lord Broers: Yes, please. information and we now need to act and make a Mr Lewis: They have recently decided to extend the judgment, and this will always be a judgment based list of allergenic foods to include molluscs and lupin, on available evidence; but we have a responsibility, and that is based on advice from the EFSA that if the advice is wrong or damaging or these also present a public health concern. The counterproductive, we ought to change it as quickly consequence of the Commission’s decision is that as possible. national legislation to add those two additional foods Lord Colwyn: And I think this advice should come to the list of allergenic foods will be implemented by from the Department rather than from the Food 23 December 2007. I am not sure that the Committee Standards Agency. is aware of that particular change? I certainly was not aware of it before I looked at the information for this Q861 Chairman: Yes, I think the questions are quite Committee. diVerent—the question the Food Standards Agency is asking. Could I also ask you on that to look at the Q864 Lord Broers: I would like to extend that a little. advice in relation to breastfeeding because we also It is the actual quantity of allergen that may be the heard about the very high allergenic potential of problem. If you take sulphites in wine, all wines using top-up formula when women are breastfeeding, contain sulphite and people will only be allergic, and there is a concern over the lack of support to perhaps, if the quantity exceeds a given amount. So allergy: evidence 313
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley that is what I see this question getting at to a certain trading standards oYcers in local areas to educate extent, because if you put on every single bottle of caterers on how to provide information on allergens wine that it contains sulphites then you are either and also be more educational in terms of their menus. stopping people drinking—which may be a very good So I would say that, although there is not a huge thing indeed, but that is not the purpose of the label, amount going on, there is work that the FSA is doing. which is meant to tell people who are going to be Also, in terms of educating young people, there is a allergic to something. So my suggestion is that it lot of work now going on in schools as well and that should actually be quantitative and say so many is part of the NSF, but also in part of the programme milligrams or such and such a percentage. that we have, the public health programme that is Mr Lewis: I think I can confirm that stopping people now getting school nurses into every school. So I drinking wine will not form part of our manifesto at would say in defence of the Department of Health the next general election! Yes, I think that is a very that we are working with the FSA on that. specific point that we ought to feed into the FSA. What I can say to my Lord is that I can write to the Committee with a bit more information about how Q866 Chairman: When we were in Denmark we the FSA are approaching their attempts, on our heard about programmes for young people in behalf, to influence the EU decisions on these particular to have their threshold of allergy to V matters, and we can ask very specifically, as part of di erent substances properly diagnosed so that they the way that we are seeking to influence the EU, knew themselves the level that would trigger a taking account of the point that you have just made. response, or would be likely to, and they also set up Mr Bell: Might I just stress that our understanding is allergy schools which were as schools for one day, that this current review that the EU is undertaking of two days, or sometimes later, to teach the young all food labelling, which, as we have been saying, we people with the allergy about the dos and don’ts and will feed into through the Food Standards Agency in the things that they could do to free them up, rather this country, is really going back to basics and than telling them all the things that they could not do, looking at all aspects of food labelling and the and to help them understand the things that they requirements for and the scope of allergen labelling could do safely and how to live a very active life as part of it. safely. It did seem there that they were empowering Chairman: I think that becomes very important the patients much more through these programmes because lupin cross reactivity with house dust mite is that were organised through the allergy centres. not something that people would initially think of in Mr Lewis: I think there is an opportunity here. The relation to food, and yet we know that asthma is Healthy Schools programme has been a tremendous triggered by house dust mite in those who are allergic success, essentially a voluntary programme and, as to house dust mites. Lord Broers. far as I know, probably the majority of schools have signed up to this, which means that they spend a lot of time as part of the school’s educational programme Q865 Lord Broers: We have also heard that on health-related issues with their students. It seems teenagers and young adults who suVer from food to me that on this specific issue there has to be a allergies tend to be less vigilant when buying food question mark, under the banner of Healthy Schools, and take risks when eating out. Who is responsible whether schools will, unless they are encouraged, be for educating these patients about how to manage focusing on some of these issues specifically, to be their condition responsibly? very frank. Mr Lewis: I think most of the work in this area is training caterers and enforcement oYcers. I am not sure, to be clear, that there is a great amount of work Q867 Chairman: These were not done through the going on, focused or targeted, if I am frank with you, schools; these were done through the allergy clinics. about young people in terms of the choices they make They called them schools because they went along to when they are eating out. There is genuinely quite learn about them rather than being treated. a bit of investment in training caterers and Mr Lewis: I am sure, but what I am saying is that this enforcement oYcers in terms of allergen-related programme would give us an opportunity to maybe issues but I am not aware of any great awareness- do some testing, some piloting and it may well be that raising programme in terms of the choices that young we want to have at an oYcial level on this one a people make. dialogue with our DfES colleagues to see whether we Mr Bromley: What I would say is that the Committee could integrate into that programme some level of is probably aware that catering establishments do not discussion about allergies and the consequences for have to list allergens on menus, but what the FSA is young people; so, rather than create a separate doing at the moment is they have quite a large programme, whether something could come out of engagement programme. They are operating training the Healthy Schools initiative which would help in courses where they have environmental health and this area. 314 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley
Q868 Chairman: Yes, but patient programmes. think you are right to raise the issue, but we have not Mr Lewis: Yes. at this stage made a decision. Mr Bromley: We know of the scheme in Denmark, it Baroness Perry of Southwark: Thank you, I think we is just that there are issues around young people that would welcome that. you cannot predict people’s sensitivity day to day Chairman: Thank you, that is extremely helpful, because it does change. So there is a risk about telling Minister. Lord Haskel. somebody, “You have this level of allergy” and then that changing, and I think we need to take account of Q872 Lord Haskel: If we move on to schools, the that as well. DfES told us that any school nurse who administers Chairman: I think they were aiming to help them an immunisation in a school setting would receive assess risks for themselves, though. Lady Platt, I anaphylaxis update training on an annual basis. think your question has probably been answered in However, we have also heard that the standard and that last answer. amount of training received varies widely between Baroness Platt of Writtle: I think so too. nurses in diVerent areas. Can you tell us who is responsible for ensuring that all school nurses receive Q869 Baroness Perry of Southwark: Minister, comparable training? Are any standards set? Who turning yet again to another topic, do you know pays? Is this the same for both private and state how many adrenaline auto-injectors, often called schools? EpiPens, are prescribed through the NHS each year Mr Lewis: First of all, I would say that any nurse and what the cost is of issuing those? responsible for immunisations should be properly Mr Lewis: I do. I can give you very precise trained as a matter of course. Most school nurses are information. In the year to 30 September 2006, employed by Primary Care Trusts and therefore they almost 165,000 prescriptions were dispensed in the have responsibility for their training. Clearly there community in England for Epipens, at a cost of about will be some who are employed directly by schools— £8.2 million. increasingly budgets are devolved to individual schools, certainly in the individual sector—and the school will then be the employer. It seems to me in Q870 Baroness Perry of Southwark: Thank you for those circumstances that there are two issues: one, that. We understand that there is disagreement that the school, in the state system or the private amongst experts as to when these EpiPens should be sector, has a responsibility to secure adequate issued and yet the decision about issuing them is left training for anybody providing those kinds to GPs, most of whom have virtually no allergy of services within their school environment; training at all. We wondered if there are any plans to equally, nurses are bound by certain professional develop national guidance over who needs to carry expectations and best practice and therefore, if they an EpiPen at all times and who does not? do not feel adequately trained in that area, they also Mr Lewis: No, there are not any plans to do that, as partially have some responsibility to access the I understand it, at this stage. training. It seems to me that the employer has a duty to make sure that anybody carrying out this role on Q871 Baroness Perry of Southwark: There is a sub their behalf is appropriately trained and there is issue about this, which we regard as extremely funding to enable that to happen; but also the important, Minister. The Anaphylaxis Campaign has professional has to make sure in terms of standards suggested that a stock of generic auto-injectors of best practice that they are up to date and are should be kept in schools for allergic children, accessing training that is appropriate. because many of them need a second dose in addition to the emergency adrenaline they carry. Do you think Q873 Lord Haskel: The problem that was put to us is this would be useful and cost eVective because, as we that the Royal College of Nursing said that virtually understand at the moment, there is a very restrictive across the nation at the moment school nurses are not policy over school nurses, that they are unable to being allowed to go on training, even the training for issue an EpiPen to a child unless it is their own their specific degree course or for their professional prescription—they cannot pass on a prescription, so training places; that they have been cut. And in to speak, which is extremely restrictive? And it does further evidence from the Royal College of Nursing often happen; I have been an EpiPen carrier myself they said that a recent RCN survey showed that and I know you do sometimes need a second dose. almost a quarter of school nurses were unable to Mr Lewis: I agree. I think it is a major issue. I think take time oV to undergo further training, and we what we need to do, because I do not think we have wondered how you reacted to that? made a decision on this in terms of schools, is to Mr Lewis: The RCN is issuing very helpful press review it, and within a relatively short period of time releases at the moment. I think we have to be very, make some decisions about what is appropriate. I very clear about this. By next year the amount of allergy: evidence 315
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley money going into the health service in this country more thought should be given to this and the policy will have tripled. Has there been a diYcult year be re-reviewed or, perhaps, one might less generously during the course of the past 12 months and has say, reviewed? that had an impact in certain health economies? Mr Lewis: An option that is available to us would be Absolutely, because the Government, for the first to ask NICE to appraise immunotherapy, but time in the history of the health service, has looked obviously what happens really on an annual basis is people in the eye and said overspending and out of that there are all sorts of competing suggestions control budgets are no longer culturally acceptable in about what we ought to ask NICE to appraise. But the health service, just in the same way that it is not we can certainly consider putting this as part of that acceptable in any other part of the public sector or process. Essentially the question, I assume, was any other sector. So it has been a diYcult year for the rhetorical in the sense that my Lord believes that it is NHS and that diYcult year has impacted in diVerent time for a fresh appraisal. areas in diVerent ways, and there is no doubt that just Lord May of Oxford: That is certainly what we like every other part of the system school nurses will heard; in fact we heard it in some rather strong terms. have been aVected by that. But we should not make One of the people who spoke to us—not even in sweeping generalised statements based on one Germany or Denmark—is a paediatrician from Cork challenging and diYcult year. To be absolutely clear University Hospital and he said that the NHS is the about where the Government’s position is in terms of laughing stock of Europe for its absence of funding and commitment to school nurses, the immunotherapy for allergic diseases. I am inclined relevant White Paper, the Choosing Health White maybe to discount that as rhetorical overstatement— Paper, made a commitment to provide new funding my own background being partly Irish—and Irish for school nurses so that by 2010 we will have at least blarney, but nonetheless it gives a sense of the sort of one full time qualified school nurse working with things we heard. We also heard that immunotherapy each cluster of primary schools and its related treatments that do not have a UK product licence can secondary school. That remains the position of the be used to treat patients on a named patient basis Government. What we also have to be clear about, in within the NHS and that struck us as a peculiar the same way as I talked about maximum devolution anomaly within the more general question. So I now of power responsibility and budgets to schools, wonder if you are, in a sense, not as up on this— is that we have a similar scenario in the National which would be fair enough—but if you could give us Health Service, in that we do not run a command and some sort of lengthy reply. control health service from oYces at Richmond House. It would be nice sometimes to be able to do so Q875 Lord Colwyn: And of course if the patient can but we no longer do, we devolve significant amounts aVord to pay for it it does work. of power and resource and budget to individual PCTs Mr Lewis: I think we ought to go away and reflect on and the key decisions that are being made in whether this ought to be a matter we send to NICE those organisations these days are to do with for appraisal; but equally we will have to come back commissioning. But in terms of commissioning, to the Committee with the process because we cannot it is absolutely clear the expectation is that guarantee that this will end up as one of the priorities commissioners in every PCT will secure the outcome this year. I think it would be about saying that, over that I have just referred to, and the outcome is a specified period, we will seek to get NICE to look at making sure that those clusters of schools in their this as one of its priorities. I would be happy to write communities have access to the nurse. Now, the to the Committee to that eVect. training related issue is of course that if you are going to employ a school nurse who is going to be fulfilling certain tasks in schools then it is the employer’s Q876 Chairman: I think one of our concerns that responsibility to make sure those people are arose, Minister, and it may be helpful for you to appropriately trained. know, from the NICE evidence that we had, was that we had the sense that immunotherapy was not really on their list at all and they did not seem to be aware Q874 Lord May of Oxford: Changing direction of the sublingual immunotherapy route, which is a little and coming back in a sense to Denmark extremely acceptable to patients and has a very good and Germany, the MHRA recommends that safety profile, and they did not seem to know about immunotherapy be restricted to patients who fail to product licensing of sublingual immunotherapy. So respond to other allergy treatments, but that is a that was our concern. And it also linked to the decision that has not been reviewed since 1994 and shortage of specialist centres who obviously will be NICE has never even carried out an appraisal of key in driving forward any such therapy, but allergen injection immunotherapy. The Committee particularly for young people: if it frees them up from heard evidence both in Germany and Denmark on being shackled by severe allergic response it can be the eYcacy of immunotherapy, so is it not time that very dramatic, and we are concerned about young 316 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley people with hay fever under performing in exams and Q879 Lord May of Oxford: Just continuing this one so on, and that it can blight their careers. So that is more moment, we heard from oYcials from the some of the background to our concern. I hope that Department of Health—and I am quoting now—that is helpful to you. “gaps in current knowledge around issues like service Mr Lewis: It is; it reinforces the point. configuration, the best skill mix, the best balance of generalist against specialist services and, also, in data on cost-eVectiveness”, that there are gaps in all of those things. More specifically, what analysis is being Q877 Lord May of Oxford: That was Lord Soulsby’s undertaken to assess whether allergy is best treated question and my question was carrying us back to by primary care workers or specialist services? We the review of services for allergy that we discussed heard quite a lot on that theme from people in general at the beginning, which, amongst other things, practice who felt that they did not know what to do recommended that Primary Care Trusts and local within their local remit. health authorities should develop local allergy Mr Lewis: I am not sure that we have a very robust services based on need. When might we look to see system which is actually providing us with reliable that being commissioned? data to inform policy development. I think that is Mr Lewis: As Lord May will appreciate, as we no probably the frank answer that we ought to give. The longer do command and control we basically issue question then is, what mechanisms are available to us guidance to PCTs, to commissioners; we have drawn to develop that kind of infrastructure and I think, to their attention to this and the possibilities of, in their be honest, it is not just the responsibility of the localities, creating specialist services, but we cannot Department of Health or government it is also the force or impose that at a local level. I could go responsibility of the Royal Colleges and also some of through a long description of the way we are seeking these specialist professionals who work in these for the NHS to work now, but the more useful and areas. constructive response to the question would be that, Mr Bromley: I think we recognise this. When Martin again, this evidence session highlights the potential Marshall, the DCMO, came and gave evidence you benefits of having a lead Strategic Health Authority questioned him on how we are going to engage with for this issue and then seeking to get that lead the service on this particular area, and the first step is Strategic Health Authority to engage with perhaps that the DCMO is organising a high level meeting one or more than one PCT within their region, to say with a number of the Royal Colleges to look at and that it would be really good if you could take address the issues that you have put forward. We also responsibility as a national lead, if you like, for have in the Department a small team that works on creating some specialist allergy services and then this particular topic, and that team will look at the consider what we can learn from those services. I future of how we develop a service around allergy, would certainly be willing to explore, as a result of and that will form part of the work in the this session, and of course to give the Committee Government Response to this inquiry that will take due credit for this, to have a dialogue with the NHS place over the summer. I think the Minister is right, about a Strategic Health Authority taking lead no, we do not have a framework set up at the moment responsibility with allergy as part of that, to see but we hope to have a framework set up when this whether they can engage with PCTs in their region to Committee has reported and when we take a view of stimulate some new specialist services. how we develop the services, as the Minister has said, through a Strategic Health Authority format or through another format. Q878 Lord May of Oxford: I take your point about Chairman: One issue that Lady Platt wanted to ask command and control but how does the Department specifically about is GP education and I think it know what local commissioning of allergy services would be appropriate to switch to that now in the are taking place? That is being informed. light of your comments, Mr Bromley. Mr Lewis: Again, it is the balance, is it not, between being accused of seeking more and more data and Q880 Baroness Platt of Writtle: We have heard in information, which is called bureaucracy, and evidence that GPs receive very little undergraduate wanting evidence to inform policy—it is a constant training in managing allergy and cannot tension. I think part of a lead Strategic Health appropriately diagnose or treat allergic diseases. Authority’s responsibility, Lord May, would be to What is the Department doing to improve allergy consider how we do on a national basis, to ensure training for GPs, either in initial training or during that we are collecting appropriate information and continued professional development? evidence to inform policy. So I would see that as part Mr Lewis: The straight answer is that we do not of a lead Strategic Health Authority’s role in this define the curriculum content for training; what we area. can do is bring this issue to the attention of the bodies allergy: evidence 317
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley that do have that responsibility—the Postgraduate accessible guidelines for GPs are very much in need. Medical Education and Training Board, and the What is the Department doing to provide guidelines General Medical Council, to name but two. So we do for GPs on this matter? not decide the content of the curriculum for training Mr Lewis: There is quite a lot of guidance available— GPs. But we share your view that early intervention good practice guidance, for example, drawn up by a is really important and for early intervention to number of Royal Colleges and other professional happen it is going to be the GP in most circumstances bodies for specific conditions. The National who is going to be absolutely crucial. I think there is Prescribing Centre has published a number of significant evidence to suggest that many, many documents to inform GPs and other health GPs have inadequate knowledge in this area. Of professionals on specific allergic conditions. NICE is course the other issue would be about continuing currently developing guidelines for atopic eczema in professional development beyond initial entry-level children. We are, as you know, as part of the review training, and again I think we need to have a dialogue that we have undertaken, committed to look at the with the relevant professional bodies that are options for referring to NICE a request to specifically responsible for that to make sure that allergies are develop clinical guidance for the diagnosis and taken more seriously than they have been hitherto. management of allergic conditions, so that is something that is active and under consideration at Q881 Baroness Platt of Writtle: This does seem to the moment. We have asked the Royal College of us to be very important indeed. How many Paediatrics and Child Health to scope work to postgraduate training places are there per annum and develop care pathways for children with allergic are there any incentives to encourage GPs to undergo symptoms, and we have also commissioned Skills for further allergy training? Would you consider Health to develop National Occupational Standards including all allergic diseases in the Quality and for the UK for allergy, and those competences Outcomes Framework for GPs? stemming from those standards would be relevant to Mr Lewis: I can give some statistics. There was a all clinical staV including GPs. So there is quite a lot survey done in 2002, and of 500 UK GPs only 50 per of guidance and guidelines out there in the system. cent had undergone training in managing allergic problems and most of them—78 per cent of that 50 per cent—as undergraduates. There was a study Q885 Earl of Selborne: You referred to the NICE done in 2006 of people who used these services and guidelines and you say they are under consideration. very interestingly 76 per cent of them felt that their We heard in March from the Chief Executive of GP did not understand their health needs at all well. NICE that these proposals were now back with the I think we have in a sense two issues: one is that Department of Health Ministers, so what happens we need every GP to have a basic minimum level now? of knowledge; we then need to find a way of Mr Bell: If I may, the position on that is that encouraging some to develop far more specialist Ministers, including Mr Lewis, are at the moment knowledge. awaiting a large submission from oYcials in the Department making recommendations for the next Q882 Baroness Platt of Writtle: Yes, because there is wave of clinical guidelines products to be referred a shortage of specialists too. to NICE. I cannot anticipate what those Mr Lewis: And on a network basis you need people recommendations will be or what Ministers will who are seen as leaders, specialists, who can then decide on the basis of them, but that is due, I am told support and influence professional colleagues, peers. by colleagues in the Department, in the next few weeks. Q883 Baroness Platt of Writtle: Perhaps on a Mr Lewis: There are obviously competing priorities regional basis. and the question for me is, if this does not make it Mr Lewis: Absolutely. Again, it is for us, I think, to into this series of referrals, whether we can commit to engage seriously with the bodies that are responsible saying that it may not happen this time but we can for training, to make sure that this issue is taken more give a specific timeframe, otherwise I think people seriously. will be quite sceptical. Baroness Platt of Writtle: We think this is vital.
Q884 Earl of Selborne: Minister, you said just now Q886 Chairman: Mr Bell, could you just clarify that many GPs have an inadequate knowledge on because I think you said Ministers—is this going to how to diagnose, treat and refer patients for allergies several Ministers or is it going to be specifically— and I think the Committee would agree with that. Mr Lewis: The NICE issue obviously cuts across— GPs, of course, get guidelines thrown at them from what we refer to NICE will cut across several all directions but this does seem to be an area where Ministers. 318 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley
Mr Bell: The process as I understand it, Lord specific reference to these 11 posts and perhaps Chairman, is that the team within the Department oYcials will be able to help me with this. that coordinates the various recommendations that Mr Bromley: Yes. We refer to the 16 Clinical have come from diVerent directions, including us, put Lectureships—that is what Sally was referring to, so together this magnum opus, which goes to Lord in fact we actually have more than the 11. Hunt as the lead Minister for NICE but is copied to all the other Ministers including our Minister, and it Q889 Chairman: Those are the Walport posts for the gives them the opportunity to comment. The Walport money? Secretary of State will then make the final decisions. Mr Bromley: Yes.
Q887 Earl of Selborne: And the Department of Q890 Chairman: Can you just clarify what “relevant Y Health o cials told us that the Department was to allergy” means because are you including in those working with the Royal College of Paediatrics and numbers dermatology, respiratory medicine and so Child Health to fulfil its pledge to develop care on? pathways for children with allergic symptoms. Can Mr Bromley: Yes. you tell us what progress has been made towards this Mr Lewis: Immunology, dermatology, respiratory and how you will disseminate these guidelines medicine and paediatric allergy and infection. through the medical community? Mr Bell: I can tell you where we are at on that. We have had constructive discussions with the Royal Q891 Chairman: And you are including the specific College of Paediatrics and Child Health and, at our allergy training posts as well, of which there are eight request, they have gone away and are working up a currently SpRs in the country, or not? scoping document at the moment for taking forward Mr Bromley: Can we get back to you on that because this work, which they are very keen to do. I am if it is possible we would like to check? I would like to hoping that we will be able to commission them to check because it is not in the written evidence. I think take this forward very quickly, with the expectation what we would like to say is that we have researched that the work would be completed by the College, what Sally has said and we are quite pleased to say bringing together all the other professional groups that, yes, the 11 are there, plus. and other stakeholders with an interest to do this development work, in the current financial year. Q892 Chairman: Can I just finish with asking you about a completely diVerent area, which is Q888 Baroness Perry of Southwark: One of our complementary medicine? We heard that a lot of witnesses, Professor Davies, told us that 11 new patients are going to complementary therapists of V training posts had been agreed to train clinical di erent sorts, often because they feel that they academics in allergy. However, other expert cannot get the services from their GP or within their witnesses were quite unaware of this. Could you area. We know that there is legislation being clarify for us whether these posts have been allocated, developed to regulate acupuncture and practitioners whether they are specific to allergy and how they will of herbal medicine. We wondered whether there are impact upon clinical practice? any plans to extend such regulation to other people Mr Lewis: I can tell you what has happened in who provide services for patients, either diagnostic or terms of training. Basically, the National Institute reportedly therapeutic? for Health Research Integrated Academic Training Mr Lewis: You are right, we have asked Professor Pathway has established academic training Pitillo to look at acupuncture, herbal medicine and programmes in strong host environments to traditional Chinese medicine, and we are waiting for provide training support for either Academic recommendations in those areas. We have also Clinical Fellowships or Clinical Lectureships. Once funded the Prince of Wales’ Foundation for identified, successful programmes may appoint Integrated Health to set up a voluntary register of trainees into the posts through local competition and unregulated professions, and we are also setting up a via the Postgraduate Deanery. A total of 17 UK working party to consider the criteria to be used programmes relevant to allergy have been funded, to decide whether a profession should or should not each for five years. During the course of these be statutorily regulated. The very direct answer to the programmes, a total of 33 Academic Clinical question, do we have any immediate plans, is no. Fellowships and 16 Clinical Lectureships will be supported. A range of universities are carrying Q893 Chairman: We have heard of the lack of out these programmes—Birmingham, Brighton evidence to support the eYcacy of some of these and Sussex, Imperial College, King’s College, treatments and yet a very high uptake and high level Manchester, Newcastle-upon-Tyne, Oxford, SheYeld of belief on the part of the public, and we wondered and Southampton. What I am unclear about is the who you felt should be pushing for and funding allergy: evidence 319
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley evaluative research of some of these diVerent Lord May of Oxford: Very quickly, and not all my diagnostic and treatment modalities? colleagues will agree with what I am about to say, but Mr Lewis: You mean who should be assessing the my own view is that one of the most under researched health benefits of these alternative interventions? areas is the interplay between health and mental state, because if you look at the studies of most of these complementary medicines what turns out is real Q894 Chairman: Yes, in terms of cost-eYcacy, benefits accrue, but if you do double-blind it does not rather than people just having pressure groups matter whether you give them the medicine or not— suggesting that some of these things should be it is the actual act of treatment. That is a comment— available or making claims on their behalf. many of the practitioners believe that they are doing Mr Lewis: I suppose evidence-based policy would be something, when in fact they are not, but the an exciting development! The answer to that is I do interplay between mental states and health is real and not know. As far as I know, at the moment the it is something that we seem to distance ourselves Department of Health is not formally undertaking from, that it belongs in the more diYcult areas of the evaluation of the impact of those interventions which will then be made public. Are there other bodies? Do social sciences and yet it is a really important thing. I oYcials know other bodies that are actively doing do not see the answer to it because no one wants to that in terms of trying to gather hard evidence in pick it up. these areas? Mr Bell: Lord Chairman, I am aware that there is Q896 Chairman: A concern that I would echo is that research that is being done by academic bodies into sometimes the wrong question is being asked in the V di erent complementary and alternative medicines, research. so it is not a completely un-researched area, but Mr Lewis: I think there is a debate beginning in this clearly there is a lot we do not know. area about well being, which is a healthy debate, Mr Lewis: I think we can perhaps write to you. which then over time may lead to a very, very Mr Bromley: I think the answer is we do not know. diVerent approach to some of these issues. There is The problem is, as you know, some of these products also the Layard work around CVT. We can agree are food; some of them are not medicines, that is the or disagree that CVT is an incredibly eVective problem at the moment. We need to look at this psychological intervention, but the point is that for a situation and say, “Where does the responsibility lie, lot of people at the root of their health problems and and how do we separate the responsibility in terms of conditions is unhappiness, depression, anxiety and whether it is a food product or maybe a cosmetic sadness about their lives genuinely, and I think we product?” I think that is the problem at the moment. would all as civilians—if we take away our respective titles—understand that that is real. The diYcult bit is Q895 Chairman: Our other concern was on the how you set about proving that and how you create diagnostic side, that there are patients who are a situation from a very, very low base where you have absolutely desperate who will be spending several suYcient evidence to suggest—which I think Layard hundreds of pounds on processes believing that that tries to present—the economic case and the societal is diagnosing an allergy, and yet the evidence is not benefits of investing far more significantly in those there that that is actually diagnosing an allergy, and kind of psychological interventions, which in the end that there is not any particular group that have a not only end up leading to a much better society and vested interest into researching into this because, happier individuals and more well individuals but unlike the pharmaceutical industry, where they will actually mean we of course spend less resources at the be producing a product which is prescribable, it does acute end of the National Health Service. I think this not fall into that group and these people are often not debate is rolling and I think it is a very important trained in scientific approaches to research; and so, debate we need to have in society. even if they do want to do some evaluation and apply for a grant, with the competition for research grants they are going to fall out before they even start. So Q897 Lord May of Oxford: If I may just say, it is a there are diYculties in kick-starting good evaluative splendid book but it is on economics and how you projects and that is the background to this question measure how well oV we are. I encouraged people at you are going to be looking into. the Royal Society to have one of our dozen a year Mr Bromley: I think when the DCMO, Martin discussion meetings on this subject. I thought it was Marshall gave evidence, this is one of the things he a good idea to do it—there is a lot of criticism for took away, as well as with the GPs’ issue—it was one doing it and some of the papers really were a bit oV of the issues he took away, and wanted us to work on putting, but nonetheless important. The diYculty is more of this issue. that the practitioners of alternative medicines would Chairman: Lord May. not welcome what I have just said—or many would 320 allergy: evidence
18 April 2007 Mr Ivan Lewis, Mr Alan Bell and Mr John Bromley not—so they are not keen on it. On the other hand, Q898 Lord Colwyn: I think I prefer you to call it many of the people in the heart of science would complementary medicine. I had a letter yesterday disagree with my statements about the need for better from George Lewith and I have left the figures understanding of the interplay. I just do not really see behind, but despite the millions of people who have how we get there from here. treatment I think the total research budget is 0.008 Mr Lewis: I do not think we should limit this to per cent of the entire budget, which is minute. alternative medicine. Every day in this country there Mr Lewis: I was not really seeking to make any are many health practitioners and professionals who statement by using the term alternative—I am are issuing prescription drugs when actually there equally happy using the term complementary, so I do would be far better solutions. That is the way that not want to provoke a debate that is not necessary. primary care frequently deals with mental health, and Chairman: Minister, can I thank you very much? I we have revolving or rotating patients who sit and fill feel as if we should continue this debate, even in up GPs practices in many parts of the country, where another forum and informally because it is absolutely the answer is the prescription in terms of the fascinating, and some of it relates to the role of the antidepressants or whatever. That is not getting to practitioners themselves on the individual patient the root of the problem, it is not being innovative and and whether they augment or decrease anxiety and imaginative and it is not trying to support the person how the whole situation is managed in helping the to change their life, if you like. I think this debate, in patients change their behaviour as well. Thank you a sense, needs to be removed from the confines of the very much for coming today, for having spent so long practice of alternative medicine and look far more giving this detailed evidence and also for oVering to broadly at “is the health service a sickness service or take away so many issues and look at them. We look is it a health service” and what do we mean by well forward to working with the Department. We will be being, which is the new, trendy, fashionable word? producing our report, obviously, but we hope it will But we need to do a lot more work in defining what be a very constructive dialogue. Can I thank you also, we mean by well being and how we go about securing Mr Bromley and Mr Bell, for having come with the it for as many people as possible. Minister today.
Supplementary memorandum by the Department of Health
You asked me to comment on a number of questions which were not explored fully during the meeting. I shall deal with each of these in turn, and add comments on a few other matters on which oYcials and I undertook to submit additional material to the Sub-Committee.
What is the Department’s view of establishing a central disease registry? (Q.832) Our view is that, in general, investment in disease research registries is not a good use of central research and development provision. Such registries are expensive to develop, and funding their long-term maintenance can create diYculties in a system that has to be responsive to changing demands and priorities. The setting up of disease registries for the purpose of clinical audit is a matter for local decision and funding.
Has the Government agreed to fund the specialist THOR schemes in the future and for how long will this funding be agreed? (Q.838)
The Health and Safety Executive (HSE) is seeking to secure the long term funding of both the THOR GP and THOR Specialist schemes of work. Representatives met with Professor Agius on 4 April and made an oVer which, if accepted, will guarantee funding of data collection within the THOR GP scheme until 31 December 2010 and the THOR Specialist scheme until 31 December 2011. Professor Agius is yet to respond formally to the oVer but is due to do so by mid-May. (Please see p 111, Supplementary Memorandum by Professor Raymond Agius). A significant reason for the delay in responding is that Professor Agius has been preparing a request seeking EU funding for his THOR related work. This process was due to be completed by 26 April. It is not clear whether any EU funding would be used to subsidise the work that Professor Agius is undertaking on behalf of HSE, or whether he intends to use it to broaden the scope or scale of his work. allergy: evidence 321
The Sub-Committee also asked (Q.843) about sponsorship of the “Bad Hand Day?” campaign. HSE developed this campaign by working in partnership with Local Authorities and industry Habia (Hair and Beauty Industry Association) and NHF (National Hairdressers’ Federation). It aims to raise awareness of dermatitis among hairdressers, and to oVer help and advice on the simple steps that can be taken to prevent it. As part of the campaign, Local Authority inspectors visited salons around the country, and ran awareness raising events for local businesses and colleges. Information on the “Bad Hand Day?” campaign, and the resources developed to support it, are available from the HSE website at http://www.hse.gov.uk/hairdressing/index.htm. HSE has formally evaluated the impact of the campaign and this has shown that it was very well received by hairdressers. HSE is now working with Local Authorities and industry to develop a second phase for the campaign, to build on this initial success and further to promote the uptake of preventative measures within salons and during hairdressing training.
Could you clarify the details of the DTI strategy for sustainable construction, the work that has been carried out so far, and how your Department might be able to work with the DTI to take the needs of allergy sufferers into account when building new homes? (Q.855)
Following a review in 2006, the Department Of Trade and Industry (DTI) is co-ordinating the current development of a combined industry/cross-Departmental strategy for sustainable construction. The proposed new strategy will provide a framework to guide future progress within the construction industry. It will go to public consultation in the near future. During that consultation, contributions on this and other matters relevant to sustainable construction would be welcomed. Responsibility for the Building Regulation, however, rests with the Department for Communities and Local Government (DCLG). Through the Building Regulations for ventilation (Part F), Government can have some control over indoor air quality in new homes, including the provision of suYcient ventilation to dilute reasonable levels of the main pollutants—which include volatile organic compounds (VOCs) and moisture— thereby stemming the development of mould growth. There is, however, still a lack of evidence on the direct impact of some types of building materials on health or the balance between the eVects of building materials, furnishings and cleaning solvents. It is not clear if the Building Regulations have powers to control use of VOC-emitting materials, even if a health case could be made. They cannot control emissions from furnishings and products that people bring into their homes. Currently, building material manufacturers are not required to declare emission levels. The Sub-Committee also asked (Q.850) about Departmental responsibilities for indoor air quality. I have looked into this complex area and an overview follows. First, I should clarify that although I made reference to the Department for Environment, Food and Rural AVairs (Defra) Air Quality Forum, that body’s remit does not include indoor air pollution. The Forum was established in 1998 as part of the requirements under the Environment Act 1995 for the Secretary of State to consult stakeholders when developing and reviewing the Government’s Air Quality Strategy. The Strategy is concerned with ambient air quality and does not cover indoor pollution. Despite this, at its quarterly meeting held on 22 March, the Air Quality Forum did specifically look at the matter of the responsibilities across a series of Government Departments. I should emphasise, however, that this was done as a single exercise simply to inform the Forum of the current position. I also undertook to write to the Sub-Committee about the Interdepartmental Liaison Group on Indoor Air Quality. The Group was originally set up by the then Department of the Environment (DOE) and was responsible for considering a programme of commissioned work around the quality of indoor air. This programme continued as the DOE later merged with the Department for Transport (DfT) to become part of the new Department for the Environment, Transport and the Regions (DETR). Towards the end of the 1990s, the programme ended and, consequently, the work of the Interdepartmental Liaison Group on Indoor Air Quality ceased. Responsibility for indoor air quality has fallen to diVerent Departments, largely as Departments have merged or new Departments have been formed. It originally sat with DOE but in 1997, when DOE and DfT merged to form the DETR, the health aspects of indoor air were assigned to the Department of Health (DH) whilst DETR retained responsibility for indoor air quality with respect to the Building Regulations. 322 allergy: evidence
In 2001, the picture changed again when DETR was ended and its work was split into a number of separate Departments. As a result, responsibility for the Building Regulations went to the newly formed OYce of the Deputy Prime Minister (ODPM), now DCLG, and the health aspects of indoor air remained with DH. This is how it currently stands. May I add that, in recent years, DH has funded the World Health Organization (WHO) to help it develop guidelines on indoor air quality. Health Protection Agency (HPA) colleagues attend its meetings. In addition, at the fourth WHO Europe Ministerial Conference on Environment and Health in Budapest in June 2004, DH and Defra Ministers, on behalf of the UK Government, made a commitment to develop and implement a Children’s Environment and Health Strategy for the UK. This would address national priorities as well as set goals to address the four key objectives, one of which is to ensure clean outdoor and indoor air. To date, much work has been done towards the UK Strategy and this is being co-ordinated by an Interdepartmental Steering Group chaired by DH, with a membership comprising representatives of relevant other Government Departments, Devolved Administrations, the Environment Agency, the Scottish Environment Protection Agency, the HPA, the Food Standards Agency and others. My oYcials will continue to work with their DCLG colleagues, and those other Government Departments as necessary, on indoor air issues.
In Q.861 you committed to review the evidence regarding peanut avoidance during pregnancy and weaning. What plans does the Department have to review its dietary guidance as soon as possible?
In my oral evidence, I referred to two (recently published studies that investigated the impact of the current Government advice on avoidance of peanuts during pregnancy and lactation. I am enclosing copies of these papers with this letter [not printed]. I also undertook to ensure that the basis for this advice would be re- evaluated as quickly as possible. This review will proceed as follows. As you are aware, the current advice, which was issued in 1998, was based on a review of all the scientific literature available at that time by one of the Government’s scientific advisory committees, the Committee on Toxicity (COT). In order to review its advice, the COT will need not only to review the two papers that I am now providing for you, but also to evaluate carefully any other relevant evidence that has become available since 1998. This is in accordance with the OYce of Science and Technology Guidelines on Scientific Analysis in Policy Making, which set out the basic principles which Government Departments should follow in assembling and using scientific advice, and the Code of Practice for Scientific Advisory Committees, which was issued in 2001. I can report that the Food Standards Agency has already begun the process of identifying and systematically reviewing the evidence, and a paper will be taken to the COT as soon as this review is complete. The COT will then consider this evidence at an open committee meeting and will issue a statement. After that, the Government will reconsider its advice in the light of the views of the COT. Given the need to evaluate fully and carefully all the relevant scientific evidence, this process is likely to take six to 12 months.
How is the Food Standards Agency attempting, on your behalf, to influence the EU review on food labelling to specify the levels of allergens in food products? (Q.865)
The current EU review is a fundamental review of all food labelling. Following initial discussions, the European Commission is expected to produce a proposal by the end of 2007. The Food Standards Agency will negotiate this proposal on behalf of the UK and will liaise with other Government Departments to agree a UK line. The experience gained in developing the guidance that the Agency published last year, on allergen management and advisory labelling, will help the UK in ensuring that future EU labelling is as helpful and informative as possible for food allergic and food intolerant consumers.
I should like to add some further detail to my reply to Q.865, regarding limits for sulphites. The current legislation requiring the declaration of allergenic ingredients does contain a threshold limit for sulphites and requires only added sulphites above 10mg/I or 10mg/kg to be declared. allergy: evidence 323
Over what sort of timescale does the Department of Health envisage asking NICE to appraise immunotherapy? (Q.876) The arrangements for selecting topics for the National Institute for Health and Clinical Excellence (NICE) work programme were changed in September 2006. Under the new system, there is a more transparent approach to assessing the suitability of topics suggested and an objective approach to prioritising them, which is supported by a larger role for NICE in the selection process. I hope the Sub-Committee will find it helpful if I outline the process of selecting topics for referral to NICE. NICE administers the initial stages of the topic selection process and is the principal point of contact for individuals and organisations wishing to submit proposals. NICE has established consideration panels dedicated to specific conditions and diseases, whose specialist composition allows topics to be assessed on their relative priority within a given specialty. Topic proposals are assessed against published DH selection criteria. Ministers make the final decisions on the referral of the NICE work programme on the basis of the advice they receive from a variety of sources including NICE, the NHS and strategic policy advice from within DH. The process for determining the next NICE work programme, its fifteenth, has not yet completed. Whilst I can confirm that there are a number of topics in relation to allergy under consideration as part of this work programme, it is not possible for me to provide any further information until the Secretary of State has taken a decision on the referral of the programme. With regard to allergen injection immunotherapy, we have passed the Sub-Committee’s views to the NICE topic selection team, who will feed the suggestion in to the topic selection process. This will allow the topic to be considered alongside all other topics in order to establish its relative importance and priority for referral. At this stage, I could not oVer a guarantee of its inclusion in the NICE work programme.
You stated that 33 advanced clinical fellowships and 16 clinical lectureships will be supported by new training programmes (Q.889). Does this figure include the eight Allergy Specialist Registrar training posts available in the UK? Could you outline which discipline each of these posts cover—for example are they specifically for allergology, immunology, dermatology or respiratory medicine? I referred to the academic training programmes that the National Institute for Health Research (NIHR) Integrated Academic Training Pathway has established, through two rounds of national competition, in strong host environments (through partnerships between universities, local NHS Trusts, including PCTs, and Postgraduate Deaneries), to provide training support for either Academic Clinical Fellowships (ACFs) Or Clinical Lectureships (CLs). In all, 17 programmes relevant to allergy (including immunology, dermatology, respiratory medicine and paediatric allergy and infection) have been funded, each for five years. During the course of these programmes, a total of 33 ACFs and 16 CLs will be supported. Details are given in the appended table. [not printed] There are six ACFs and two CLs awarded solely in allergy. However, it is not possible to say whether these are the same as the eight allergy Specialist Registrars. The reason is that, although the scheme provides funding for posts, it is up to the local institution how it uses the funding to create posts and who is appointed to them. For ACFs, 25 per cent salary (for up to three years) and for CLs, 50 per cent salary (for up to four years) is new funding to protect time for academic activity. It is up to the hosting partnership to integrate this new funding with existing posts. In some cases, whole new posts are being created locally where additional funding can be found. Not all of these posts have yet been filled, as far as we understand.
In Q.893 you commented on funding for the Prince of Wales Foundation for integrated health and the UK working party to consider statutory regulation. Could you provide some further information about these groups, the work they are carrying out, and the level of funding and support they receive from the Department of Health? In previous evidence we have referred to the joint working group (JWG), chaired by Professor Michael Pittilo, which we have set up actively to prepare for statutory regulation of acupuncture, herbal medicine and traditional Chinese medicine. JWG members receive funding from DH for travel expenses, including loss of earnings where, appropriate. Our budget for the JWG is £25,000 for 2007–08. The Government currently has no plans to extend statutory regulation to any other professions. However, DH has commissioned the Prince of Wales’ Foundation for Integrated Health (FIH) to develop voluntary self- regulation amongst a range of currently unregulated professions. The professions working towards self- regulation are Alexander Technique, Aromatherapy, Bowen Technique, Cranial Sacral Therapy, Homeopathy, Massage Therapy, Naturopathy, Nutritional Therapy, Reflexology and Yoga Therapy. 324 allergy: evidence
The FIH has undertaken a public consultation exercise, which closed at the end of July 2006. The results show a clear mandate to move forward with a federal approach to regulation. The FIH has set up a joint working group to move towards the agreed federal model for self-regulation. We have awarded a Section 64 grant to the FIH for the above work, totalling £900,000 over the three years 2005–06 to 2007–08.
In oral evidence (Q.893), I also mentioned the proposed UK working party to consider statutory regulation. Paragraph 7.9 of the White Paper Trust, Assurance and Safety—the regulation of health professionals in the 21st century (published on 21 February 2007) says, “For emerging professions, the Department will establish a United Kingdom working party to develop criteria to determine which roles should be statutory regulated.” DH will be announcing its proposals for taking forward the policies set out in the White Paper at a direction- setting event at the beginning of June. We shall announce the working groups and their terms of reference at this event.
The Sub-Committee asked as well (Q.894) about funding for evaluative research on CAM diagnosis and treatments. In recent years, the Government has made a substantial investment in CAM-related research. Following the recommendations of the House of Lords Sixth Report on Science and Technology (2000), over £3.5 million of new funding is being invested in research and development under the National Complementary and Alternative Medicine Personal Award Scheme. The Scheme is designed to develop research capacity in the area of CAM, and to promote the development of a robust research evidence base in the future.
DH has funded a programme of research at the University of SheYeld on complementary medicine in primary care, and research studies on the use of CAM in the care of cancer patients. The National Coordinating Centre for Research Capacity, as well as being responsible for the personal award scheme, has contributed funding to CAMEOL (Complementary and Alternative Medicine Evidence Online). This programme, funded at the level of around £300,000, involves a detailed review and critical appraisal of the published research on specific complementary therapies, focusing on key areas of NHS priority—including chronic conditions.
The Government’s health research strategy; Best Research for Best Health, will allow researchers to bid for research in the area of CAM. The strategy includes a responsive funding scheme—the Research for Patient Benefit programme—that is open to research proposals on CAM therapies, among other topics.
Finally, the Committee has also been made aware of the Skills for Health team which are establishing a Project Reference Group to develop National Occupational Standards for Allergy Services. l would be very grateful if you could clarify how the Skills for Health team relates to the Allergy Services Review team in your Department and what work you plan to carry out together on this project?
I mentioned on 18 April (Q.885) that DH had commissioned Skills for Health to develop National Occupational Standards (NOS) for the UK for allergy. This was one of the next steps identified in our review of services for allergy. NOS will help employers determine the skills needs of staV involved in allergy. Employers and education and training providers will be able to integrate the NOS into training programmes. The DH allergy services review team is represented on both the project executive group and the strategy group for this project, and also attends meetings of the national reference group, which brings together a wide range of stakeholders. We expect the NOS for allergy to be produced by December 2007.
Following your letter of 24 April, you also asked a further question on behalf of the Sub-Committee—
In the evidence, you have said that the cost to the NHS of allergies is over £1 billion. To put this in perspective, what is the overall cost of the NHS? And can you provide a source for this figure?
The source for the estimated direct cost to the NHS of managing allergic diseases is the following journal article: Gupta R, Sheikh A, Strachan DP, Anderson HR. Burden of allergic disease in the UK: secondary analyses of national databases. Clin Exp Allergy 2004; 34:520–6.
Total NHS expenditure in England has increased from £33.0 billion in 1996–97 to £75.8 billion in 2005–06. Investment is expected to rise further, to £90.7 billion in the current financial year. This extra money, most of which is held locally, has improved access to healthcare for millions of people. allergy: evidence 325
Finally, I should like to clear up some apparent confusion that arose from my response to Q.845, in which one of the points I made was that “hypoallergenic” is a medicinal claim and, if made for a medicine, would have to be supported by clinical data before it was given a marketing authorisation by the MHRA. I was not suggesting that the term “hypoallergenic would be thus defined in the Regulations to implement the Unfair Commercial Practices Directive, to which I had just referred and to which I subsequently returned. 14 May 2006
Letter from the Advertising Standards Authority
Introduction 1.1 The Advertising Standards Authority (ASA) welcomes the opportunity to submit written evidence to this inquiry. The ASA is responsible for supervising the self-regulatory system for advertising standards in both broadcast and non-broadcast media, ensuring that all advertisements, wherever they appear, are legal, decent, honest and truthful. 1.2 This submission will address the following points: 1.2.1 The role of the ASA. This submission aims to provide a brief overview of the advertising self- regulatory system in the UK and the ASA’s relationship with relevant statutory regulators. 1.2.2 Respond to your questions about the ASA’s approach to regulating advertising claims and, in particular, how we would go about investigating claims that state a product’s suitability for those suVering allergies.
2. About the ASA 2.1 The ASA is the UK self-regulatory body for ensuring that all ads, wherever they appear, are legal, decent, honest and truthful. The ASA has been responsible for policing non-broadcast advertising standards for more than 40 years. The success of the self-regulatory system was recognised in November 2004 when Ofcom contracted-out the regulation of broadcast (TV and radio) advertising to the ASA system. This move was approved by Parliament and created a “one stop shop” for advertising complaints. 2.2 The ASA administers three main advertising standards codes. Two industry bodies, the Committee of Advertising Practice (CAP) and the Broadcast Committee of Advertising Practice (BCAP) are responsible for maintaining the Advertising Standards Codes. CAP is responsible for the non-broadcast Code and BCAP is responsible for the TV and Radio Codes. 2.3 The full names of the Codes are: — The British Code of Advertising, Sales Promotion and Direct Marketing (“the CAP Code” (non- broadcast)). — The BCAP TV Advertising Standards Code. — The BCAP Radio Advertising Standards Code. 2.4 Further information about CAP, BCAP and the Codes can be found at www.cap.org.uk. 2.5 The ASA receives complaints from both the public and the industry about advertisements that are alleged to have breached the Advertising Codes. 2.6 The ASA system operates within a legal framework. For non-broadcast advertising the ASA is the “established means” for enforcing the Control of Misleading Advertisement Regulations 1988 (as amended) (CMARs). The OYce of Fair Trading acts as a legal backstop to the system for misleading advertisements. The ASA’s role in regulating misleading advertising is unlikely to alter under the Unfair Commercial Practices (UCP) Directive. 2.7 As already mentioned, for TV and radio advertising, the ASA operates in a co-regulatory partnership with Ofcom. Therefore, Ofcom acts as a legal backstop to the broadcast side of the ASA system. 2.8 The rationale behind creating a “one stop shop” for all advertising complaints was to simplify advertising regulation. Dealing with a single regulator makes it easier for consumers to complain and is simpler for advertisers to work with. The ASAS “one-stop shop” is in line with better regulation principles. 2.9 All the costs for running the ASA are met by a levy of 0.1 per cent on advertising space paid by advertisers and collected by at arms-length from the ASA by the Advertising Standards Board of Finance and its broadcast equivalent (Asbof and Basbof, www.asbof.co.uk). 326 allergy: evidence
2.10 Further information about the ASA and the work that we do can be found on our website at www.asa.org.uk. The website also contains a searchable database of all our adjudications from the past five years.
3. Responses to the Committee’s Questions
3.1 “Is the use of the phrases ‘hypoallergenic’ or ‘dermatologically tested’ regulated in any way by the Committee of Advertising Practice (CAP) code?” As already mentioned, there are three Advertising Standards codes regulating advertising in the broadcast and non-broadcast media. These Codes do not provide specific rules on allergy claims or “hypoallergenic” and “dermatologically tested”. Providing code rules on every conceivable advertising claim would render the Codes un-navigable and cumbersome, however the Codes do provide sensible rules on misleading advertising to which all advertisers must adhere. Advertisers that wish to make a claim about their product, including a scientific or allergy claim, must hold substantiation prior to making that claim. In particular, scientific claims must be supported by robust and independently verifiable evidence. The burden of proof falls on the advertiser; it is not for the ASA to prove that the claim is untrue. I have enclosed a Help Note that has been drafted by CAP indicating the level of substantiation required under the Codes (see Annex 1). [not printed]
3.2 “Has the ASA had any previous experience of implementing these regulations?” The ASA receives more than 20,000 complaints a year and approximately 75 per cent of these relate to misleading advertising. Although the ASA does not receive large numbers of complaints about allergy claims in advertising, it has investigated such claims in the past (see 3.3 below). Problems with misleading claims has led CAP to issue a Help Note providing guidance to advertisers on what can and cannot be stated in such ads (see Annex 2). CAP has also issued a Help Note on vacuum cleaner advertisements, which includes a section on allergy claims (see Annex 3). [not printed] The ASA’s adjudications are published on a weekly basis and can be found on our website.
3.3 “Has the ASA ever received any complaints regarding the use of this terminology, and if so, were these complaints upheld?” The ASA has received complaints about allergy claims in advertisements. These complaints have led to 24 published adjudications in the last five years, of which 19 were upheld fully or in part. I have enclosed some notable adjudications (see Annex 4). The ASA considers each complaint on a case-by-case basis. If the Committee has concerns about any specific advertisements, we would be more than happy to look into their complaint. Complaints can be made via our website, or by email, fax, phone, or letter. I have enclosed a complaints booklet for your information.
3.4 The Unfair Commercial Practices Directive takes effect in April 2008. To what extent will this help the ASA regulate the use of misleading claims? As the Committee is undoubtedly aware, the UCP Directive is a framework Directive, meaning that it primarily provides general legal principles with which business must comply ie businesses should not trade unfairly; should not mislead by action or omission and should refrain from aggressive business practices. That said, the Annex I of the Directive does provide a list of commercial practices that are considered to be unfair in all circumstances. One of these practices is, “Falsely claiming that a product is able to cure illness, dysfunction or malformations” (annex practice 17). The DTI is expected to publish further information on 29 May 2007 on how this section of the UCP Directive can be enforced under UK law by statutory enforcers. However, regardless of the DTI’s anticipated statement, the new provisions in the UCP Directive are unlikely to alter the ASA’s interpretation of what is or is not permitted in advertisements in relation to allergy claims. This is because the UK Advertising Codes and existing legislation have, for a long time. provided the level of consumer protection that the UCP Directive will, in future, provide for all EU citizens. I do hope that this submission fully answers the Committee’s questions about advertising regulation in this area and reassures the Committee that the ASA is committed to protecting consumers and ensuring high standards in advertising. allergy: evidence 327
Annex 1 Help Note on Substantiation for Health, Beauty and Slimming Claims. [not printed] Annex 2 Help Note on Asthma and Allergy Claims in Marketing for Devices. Annex 3 Help Note on Vacuum Cleaner Marketing. [not printed] Annex 4 6 ASA adjudications: Deal TV Limited (9 May 2007). Air Ion Technologies Ltd (14 February 2007). Usave.tv (22 November 2006). Sharp Electronics (UK) Ltd (6 October 2004). Samsung Electronics UK Ltd (16 June 2004). Medivac Healthcare Ltd (19 February 2003).
Annex 2
Committee of Advertising Practice (Non-broadcast)
HELP NOTE ON ASTHMA AND ALLERGY CLAIMS IN MARKETING FOR DEVICES
CAP Help Notes oVer guidance for non-broadcast marketing communications under the British Code of Advertising, Sales Promotions and Direct Marketing (the CAP Code). For advice on the rules for TV or radio commercials, contact the BACC www.bacc.org.uk for TV ads or the RACC www.racc.co.uk for radio ads.
These guidelines, drawn up by the Copy Advice team, are intended to help marketers, agencies and media interpret the rules in the British Code of Advertising, Sales Promotion and Direct Marketing as far as they relate to the subject discussed. They neither constitute new rules nor bind the ASA Council in the event of a complaint about a marketing communication that follows them.
Asthma and allergies aVect people in diVerent ways. Not only are asthma attacks and allergic reactions often triggered by diVerent allergens, but one suVerer might have a much higher tolerance of an allergen than another. It is therefore diYcult to predict the benefit, if any, to an individual of reducing the number of allergens in their environment by using devices such as specially designed vacuum cleaners, bedding and air filters.
1. Marketers who claim that their device can reduce the amount of allergens in the environment should hold relevant substantiation. Claims such as “Product X removes 99 per cent of house dust mite faeces” are likely to be acceptable if marketers can prove them.
2. Marketers who claim that reducing the amount of allergens in the environment can benefit the health of asthma or allergy suVerers should be able to support these claims with satisfactory clinical trials on human subjects. Claims such as “Product X removed 99 per cent of irritants”, “Product X removes 99 per cent of house dust mite faeces, providing relief . . .” and “Product X removes 99 per cent of house dust mite faeces, a common trigger for reactions” are unlikely to be acceptable in the absence of these clinical trials.
3. Marketers who have proved that their product can benefit the health of asthma or allergy suVerers equally should not imply that all asthmatics or allergy suVerers can benefit where this is not the case. It may be necessary to qualify a claim to reflect, for example, that only those suVerers whose reactions are triggered by house dust mite faeces might benefit.
Advice on specific marketing communications is available from the Copy Advice team. The CAP website at www.cap.org.uk contains a full list of Help Notes as well as access to the AdviceOnline database, which has links through to relevant Code rules and ASA adjudications.
August 1997 Revised: March 2003 328 allergy: evidence
Annex 4
Deal TV Limited Date: 9 May 2007 Portland Media Group Ltd Media: Television Sector: Health and Beauty
Complaint Monitoring staV viewed an ad for Miracle Spring Water and Miracle Olive Oil Soap on Deal TV, a teleshopping channel. The TV evangelist Reverend Peter PopoV said viewers who called in to receive the Miracle Spring Water and obeyed the instructions would receive money, be oVered a house, a car, be healed from allergy problems, chest pain, heart burn and high blood pressure and lose weight. He claims “Obey, move in obedience and you will literally see the angels of the Lord bring money to you . . .” Reverend Peter PopoV siad “You’ve had pain, it’s because of a tumour in your stomach, right there by your navel, it’s more or less on the right side and there’s been pain. Four surgeries, I just believe now that Doctor Jesus is going to touch everything that’s not right and make it right, make it new . . . In the name of Jesus Christ of Nazareth I command these things to dissolve”. [Peter PopoV puts his hand on woman’s head and she collapses]. An assistant said “She got the miracle spring water, she followed the instructions and just a little while later moved out of the slums into owning her very own home. Amen. God gave you a house.” The woman responded saying “Yes he did. Praise God. Yes he did.” The assistant said “Did you use the Miracle Spring Water?” The woman said “Yes, I followed the instructions and a couple of days later you wrote me and said I would get a house, I would get a car”. A testimonial claimed “Since I received your Miracle Spring Water my mom was healed and can walk again after a bad fall. My son was healed from allergy problems and my 17 years of chest pain, finger pain and heart burn are all healed. I believe you are the 100 per cent prophet of God”. Another testimonial claimed “I received your Miracle Spring Water when I saw you on TV. You said someone was going to get good news from the doctor. My blood pressure was 201/100. After the Miracle Spring Water my doctor said it [sic] was only a few days my pressure was down and I had lost 8 lbs”. Reverend Peter PopoV said “We are going to pray. We are going to send the anointed word out over the airwave. And Liz, so many people tell me that they’ve touched our hands as a point of contact and seen a miracle. We are going to believe God right now for a mighty miracle touch. Father in heaven, right now, in the name of Jesus I take authority over every sickness, aZiction, infirmity and disease. I take authority over this onslaught of financial attacks that has come against the people of God right now. I bind the forces of the enemy now. And Lord Jesus I release abundant blessings until each and everyone who is watching right now in Jesus’s name. It’s done, Liz I can just feel the burdens rolling away I can feel bondages being broken I can feel healing power flowing, do you feel that? I feel that diabetes is going away”. Another TV evangelist, Dr Paul Lewis, promoted the Doctor Paul Lewis Miracle Olive Oil Soap and gave examples of some healings. Harry and Harriet McCain were with him and reminisced about the healings. Harry McCain said “As a matter of fact you had given him a bar of soap because he had some things going on within his body. A lot of people don’t believe in the miracle olive oil soap. It works. It’s not a gimmick, it’s real. You told him to wash for several days and he had a back injury and he had some things going on in his stomach and all of that went away . . . He was totally blind to the point that his eyes were white when you took the sunglasses oV. So you know that he couldn’t see anything. And so you prayed for him and you told him look, you’re going to see. And the whole place became silent. You could hear a pin drop. And he said you are going to see this night. After this night your sight after washing with the soap is going to get better and better and better until you can see totally. There’s something about the soap. Amen. We get so may calls about this soap saying what did you put in that soap? The amount of testimony we’ve been getting of people who’ve been healed from cancer, AIDS I mean AIDS! I mean doctors don’t have a cure for AIDS or cancer and the amount of testimony we are getting. Man of God, it’s real, Jesus it’s real”. Dr Paul Lewis recounted how he had visited a mosque “that day in that temple about 10 of those Muslim got me down in that basement and we sit around and they say tell me a little bit about your Jesus. And I begun to tell them about my Jesus and can I tell you even to this day some of those Muslim, right now, is coming to my church”. Harriet McCain said “You said to her believe woman, believe woman that you can get up out of that wheelchair. Raise yourself up and believe by the power of God that God can heal you. She hadn’t walked for years. She hadn’t walked for years, couldn’t move for years, for years, for years. And you told her wise up allergy: evidence 329 woman because you can do it—daughter of God, wise up . . . And she began to raise herself up and it took me back to the woman with the issue of blood, she did not want to miss her moment because if she’d have missed her moment Dr Paul, she would have missed her opportunity and then she would have missed her blessing and I can look at this woman’s face and she said I’m gonna get out of this wheelchair one way or the other and I am not going to miss my opportunity. And she raised herself up and it was, she got up out of that wheelchair and, when she got up out of the wheelchair she began to walk and then when she got up and she walked, she put you in the wheelchair and she begun to push you through the aisles, that’s the power of God. And that was the point of contact and you’ve been saying the point of contact and with this, this oil, this olive oil, that you have, the miracle olive oil that you oVer free, free, free, it’s free”. Chanice said “I’ve used the free olive oil soap and the pain that I had, Dr Paul, all through my body, all through her body, all through her body, has been gone. And listen to this Dr Paul. I’ve used the olive oil soap, the miracle olive oil soap, and I’ve even lost weight. You don’t have to go to the gym. You don’t have to go to the gym. So if you wanna lost weight. That’s right. Call for the miracle oil soap. Amen. Amen. O yeah. Come on call for it, and God will let you lose weight. Amen”. Dr Paul Lewis said “James 5:14 said—Is any sick among you? Let him call for the elders of the church and he shall anoint him with oil, miracle olive oil soap, and the prior of the saints shall save the sick and the Lord will raise him up”. The on-screen text quoted from the Bible [Is any sick among you? Let him call for the elders of the church; and let them pray over him, anointing him with oil in the name of the Lord [James 5:14]. A testimonial said “Since I used the soap, the chemo makes my bones ache and I mean have no energy. I have had all the energy and haven’t had any bones aching, no muscles aching and I just thank God that I’m healed”. Dr Paul Lewis said “Pick up the phone right now and call that number. It’s toll-free. You don’t even have to pay a penny”.
Issue Monitoring staV challenged whether the ads: 1. exploited vulnerable viewers; 2. expounded religious beliefs and referred to individual experiences associated with a doctrine; 3. claimed the products would cure cancer, AIDS, and other serious medical conditions; 4. made medicinal claims for products that did not hold a marketing authorisation under the Medicines Act 1968; 5. complied with rule 8.4.3 (Predictions of weight loss); 6. would cause serious or widespread oVence against generally accepted moral or cultural standards; Monitoring staV challenged whether: 7. evidence existed to substantiate the claims that people’s financial circumstances would change after receiving the Miracle Spring Water; 8. using the prefix “Doctor” for Paul Lewis implied a professional recommendation for the product; 9. oVering the soap and water as treatment for various medical conditions was a breach of rule 8.2.6; 10. the channel had sought suitably qualified medical advice on the eYcacy of the Miracle Spring Water and the Miracle Olive Oil Soap’s slimming eVects; 11. the on-screen telephone number was “toll-free” as claimed.
BCAP TV Advertising Code 10.13; 5.4.4; 10.8; 10.10; 5.1; 5.2.1; 5.2.2; 8.1.1; 8.2.9; 8.2.3; 8.4.3; 6.1; 8.1.2(a); 8.1.2(c); 8.2.6; 8.4.2; 5.3.1
Response Portland Media Group Ltd first said they had subleased the channel to a third party who had aired the ads on the understanding that they had been shown on other channels. Then, in a written response, they accepted that they had breached the Code and said that they had withdrawn the ads when the breach was brought to their attention. Later, they permanently stopped the broadcast of Deal TV and surrendered its Ofcom licence. They added that ads had been broadcast on two occasions only and, because of an isolated administrative 330 allergy: evidence error, caused by the proposed re-location of parts of the business to the USA, the tapes had not been viewed by their compliance oYcer as standard. They believed that no-one had ordered the products as a result of the broadcasts.
Assessment
1. Upheld The ASA considered that the references to healing, the testimonials of those who had been healed and references to people receiving “a miracle touch from God” if they called to order the Miracle Spring Water or the Miracle Olive Oil Soap breached the Code. We considered that the ads exploited vulnerable viewers. The ads breached CAP (Broadcast) TV Advertising Standards Code rules 10.13 Vulnerable viewers and 5.4.4 (Testimonials).
2. Upheld We considered that the quotes from the Bible, Reverend Peter PopoVs reference to “We are going to pray, we are going to send the anointed word out over the airwave . . .” and his instruction that “it’s not the water that brings the miracle, it’s the obedience to the instructions of the servant of God that releases the miracle in your life” expounded doctrinal beliefs that were prohibited by the Code. The ads breached CAP (Broadcast) TV Advertising Standards Code rules 10.8 (References to beliefs) and 10.10 (Benefit claims).
3. Upheld We noted Deal TV had not sought independent medical advice on the safety and eYcacy of the Miracle Spring Water or of the Miracle Olive Oil Soap and had not established whether reputable scientific evidence supported the claims. The ads breached CAP (Broadcast) TV Advertising Standards Code rules 5.1 (Misleading), 5.2.1 (Evidence), 5.2.2 (Implications), 8.1.1 (Assessment of claims) and 8.2.9 (Cure).
4. Upheld We considered that the claims that the Miracle Spring Water had healed people suVering from chest pain and heart burn and high blood pressure and that the Miracle Olive Oil Soap had healed a blind man and people with cancer and AIDS were medicinal claims. The ads breached CAP (Broadcast) TV Advertising Standards Code rule 8.2.3 (Products without a marketing authorisation).
5. Upheld We considered that the testimonial from the woman who claimed to have lost 8 lbs in a few days after receiving the miracle spring water did not comply with the Code because the rate of the weight loss was too rapid to comply with accepted good medical and dietary practice. We considered that the testimonial from Chanice who claimed to have lost weight from using the Miracle Olive Oil Soap did not comply with the Code because the period over which the weight loss was achieved was not specified. On this point the ads breached CAP (Broadcast) TV Advertising Standards Code rule 8.4.3 (Prediction of weight loss).
6. Upheld We considered that the reference to converting Muslims in their place of worship would cause serious or widespread oVence. The ad breached CAP (Broadcast) TV Advertising Standards Code rule 6.1 (OVence). allergy: evidence 331
7. Upheld No evidence was submitted to substantiate the testimonials that claims an improvement in financial circumstances after receiving the Miracle Spring Water. We concluded that the claims were misleading. The ad breached CAP (Broadcast) TV Advertising Standards Code rules 5.1 (Misleading) and 5.2.1 (Evidence).
8. Upheld We considered that referring to Paul Lewis as “Doctor” implied he was qualified to give professional advice on health matters. Also, we considered that the products name, “Dr Paul Lewis Miracle Olive Oil Soap”, was a reference to approval of or preference for the products by Dr Lewis. The ad breached CAP (Broadcast) TV Advertising Standards Code rule 8.1.2 (a) and (c) (Impressions of professional advice and support).
9. Upheld We considered that Reverend Peter PopoVs claim to “take authority over every sickness, aZiction, infirmity and disease. I take authority over this onslaught of financial attacks that has come against the people of God right now. I bind the forces of the enemy now. And Lord Jesus I release abundant blessings until each and everyone who is watching right now in Jesus’s name. It’s done, this I can just feel the burdens rolling away I can feel bondages being broken I can feel healing power flowing, do you feel that? I feel that diabetes is going away” might give the impression that medical consultations were not necessary. The ads breached CAP (Broadcast) TV Advertising Standards Code rule 8.2.6 (Conditions requiring medical attention).
10. Upheld We noted Deal TV had not sought suitably qualified medical advice on the eYcacy of the Miracle Spring Water and the Miracle Olive Oil Soaps slimming capabilities. The ads breached CAP (Broadcast) TV Advertising Standards Code rule 8.4.2 (Requirements for medical advice).
11. Upheld We noted the on-screen telephone number was an 020 7 number and so not free as claimed. The ad breached CAP (Broadcast) TV Advertising Standards Code rule 5.1 (Misleading) and 5.3.1 (Accurate pricing). We noted the two contradictory responses. We were concerned that, as the licence holders, Portland Media Group Ltd was not entitled to sublease a licensed service and was wholly responsible for that service and its compliance with the conditions of the Licence. We welcomed Portland Media Group Ltd’s prompt action in removing the ads and surrendering the Licence. We were concerned that the broadcaster had so seriously breached the Code and because of the seriousness of the breach, were minded to refer the Portland Media Group Ltd to Ofcom for the consideration of a statutory sanction. But, because the Licence had been surrendered, we considered that no other action was needed.
Action The ads must not be shown again.
Air Ion Technologies Ltd Date: 14 February 2007 Media: Magazine Sector: Health and Beauty 332 allergy: evidence
Complaint A magazine ad, for Myairzone an air purifier, claimed “Clears the air of pollutants, dust mites, cold and flu bugs, fungal spores, pet and animal dander, smoke, moulds . . . What our customers say: From our 2006 customer survey, Myairzone is used for asthma, anxiety, bronchitis, hayfever, headaches, migraines, infection avoidance, odour removal, pet allergy, skin conditions, deepens sleep, smoke clearance, driving, working, dust mite allergy and mould . . .”.
Issue 1. The complainant challenged the eYcacy of the product. 2. The ASA challenged whether the claim “What our customers say: From our 2006 customer survey, Myairzone is used for asthma, anxiety, bronchitis . . .”, misleadingly implied that the device could relieve, or treat, the symptoms of the listed conditions.
The CAP Code 3.1; 7.1; 50.1; 50.3
Response Air Ion Technologies (Air Ion) explained that the purpose of the product was to claim the air in close proximity to the user; they said they believed it was analogous to a water purifier. They said the process had been tested in independent trials by the Workplace Environment Science & Technology Research Association (WESTRA) and the Universities of Surrey, Leeds, Southampton and Reading and its ability to clear the air of various particles had been demonstrated by WESTRA regularly by using a particle counter at clients’ premises. They also claimed that the product cleared the air of various micro-organisms and said this had been demonstrated by researchers at Leeds and Southampton Universities. They sent a presentation from the Healthy Buildings Symposium in June 2006 and a copy of their customer satisfaction survey as substantiation for the advertised claims. They pointed out that they had a 60-day money back guarantee that allowed purchasers to assess the value of the product for themselves and obtain a full refund, including postage, if they were not satisfied.
Assessment
1. Upheld The ASA considered that the claim “Clears the air” implied the product removed all airborne allergens. We noted the information Air Ion had supplied as substantiation was a short-term study on the impact of improved air quality on productivity and health in the workplace. Because it did not support the implication that the advertised product removed all pollutants and because it was not designed to be controlled for a placebo eVect, we considered that the study was insuYcient to support the claim. Furthermore, we noted Air Ion had not provided robust, placebo-controlled clinical studies that showed the product removed allergens from the surrounding air of the user’s homes, inside and outside, or for any specific irritant such as animal dander. We concluded that Air Ion’s submissions were insuYcient to prove the eYcacy of the Myairzone.
2. Upheld We noted the customer satisfaction survey had a very high response rate and, from the graph provided, customers seemed to have enjoyed an improvement in their various symptoms. We nevertheless noted that it was impossible to know from the questionnaire whether any perceived change was directly attributable to the product. We considered that the claim implied the device could relieve, or treat, the symptoms of the listed conditions including the serious medical condition of bronchitis. Because Air Ion had not provided product- specific, clinically controlled trials on suVerers of these conditions to prove the eYcacy of the product, we concluded that the claim was misleading. We were also concerned that the references to bronchitis and migraines, serious medical conditions, could discourage consumers from seeking help from a suitably qualified medical practitioner. On points 1 and 2, the ad breached CAP Code clauses 3.1 (Substantiation), 7.1 (Truthfulness), 50.1 (Scientific substantiation) and 50.3 (Discouragement of essential treatment). allergy: evidence 333
Action
We told Air Ion not to repeat the ad and advised them to consult the CAP Copy Advice team before advertising again.
Usave.tv t/a Save. TV Publish Date: 22 November 2006 U Save TV Ltd Media: Television Sector: Retail
Complaint
An ad for a silk-filled duvet on U Save TV claimed “It’s filled with 100 per cent silk and it’s got a very beautiful 100 per cent cotton casing as well. So it’s something that actually helps your body to breathe as you sleep at night . . . Does that mean that it actually keeps you cool? Because I must admit when the summer starts coming I wake up sometimes in a hot sweat . . . Are you using the same duvet that you sleep with in the summer and the winter? You know, yes, I am actually. Well, you don’t have to worry about having a summer duvet or a winter duvet because the moisture will actually just evaporate. This is absolutely breathable. So this could actually be a summer duvet and a winter duvet? . . . The thing that I find quite amazing about this is the fact it keeps you warm in the winter yet it lets you breathe in the summer as well and so you actually save money on not having to buy a summer duvet and a winter duvet. You have this one all the year round. Absolutely, and so you don’t have to worry about storage so much because you’ve only got the one.”
“It’s great news for allergy suVerers as well . . . There are health properties along with this as well, real benefits for your health. Now because it doesn’t actually retain any moisture it means bed bugs can’t actually live in here. They are not welcome. It’s the bed bugs isn’t it that actually cause the problems. It’s the droppings of bed bugs which causes asthma and eczema and your itchy skin . . . It’s 100 per cent hypo-allergenic . . . it actually breathes with your skin . . . It will actually adjust to your temperature as well: so when you are sleeping in the winter it keeps you warm, in the summer it will keep you cool . . . It’s got great health properties as well: asthma suVerers, allergy suVerers, hello, this is for you!”
The voice-over on the oVer page stated . . . including health properties which help relieve itching caused by skin conditions, 100 per cent breathable . . .”.
Another ad, for a memory pillow, claimed “this pillow is going to support your head. It’s going to mean there is less movement of the joints, the distribution of your weight is going to be maximised and, because you’re moving around less, if you’ve got any aches and pains or joints that are really achy, you’re going to possibly avoid that sort of problem. Do you know what else this is great for? If you’re a snorer . . . or you sleep next to a snorer and they keep you awake why don’t you get one of these for them? . . . Your head just rests so comfortably into this pillow, it’s supporting your neck. In fact it’s just lifting your neck very slightly, clearing your airways, so you can breathe air straight down into your lungs which could reduce your snoring”.
The text on the oVer page stated that the pillow would “relieve pain and reduce snoring”.
Issue
BCAP staV challenged whether the duvet would:
1. help the body to breathe;
2. prevent bed bugs and their droppings and thereby help asthma and eczema suVerers;
3. be 100 per cent hypo-allergenic;
4. adjust to the body’s temperature and be warm in the winter and cool in the summer.
5. BCAP staV challenged whether the pillow would reduce snoring and help relieve pain. 334 allergy: evidence
BCAP TV Advertising Code
5.1; 5.2.1
Response
U Save TV submitted evidence of a study that demonstrated the eVectiveness of a special sericin-free silk fabric in the treatment of young children aVected by atopic dermatitis (AD). The study explained “silk also helps to maintain the body temperature, by reducing the excessive sweating and moisture loss that can worsen xerosis” although “the type of silk fabric generally used for clothes is not particularly helpful in the case and dressing of children with AD as it reduces transpiration and may cause discomfort when in direct contact with the skin”. The study stated “the clothes used in the present study are made of woven silk where the special properties of silk are enhanced: the fabric allows the skin to breathe and the sensation does not bother the wearer; it also has a high capacity to absorb sweat and serious exudates (up to 30 per cent of its weight without becoming damp)”. The study stated the fabric had a waterproof, durable, antimicrobial finish. The study noted that “recent studies have suggested that cotton may also present a roughness that irritates the skin of children aVected by AD”. The study tested children wearing the special silk clothes against a control group that wore cotton clothing. The study concluded that “the use of sericin-free silk products would appear to alleviate the symptoms of AD”.
The study’s introduction stated that one of the many factors known to worsen AD was house dust mite. The study explained that “the final textile products of silk are mostly non-allergenic”. 1. U Save TV explained that they had meant to state merely that silk was used as the ultimate breathable material; with its large fibres reducing thermo conductivity, either trapping air next to the skin to keep one warm in the cold or drawing it away from the body in hotter temperatures. The broadcaster admitted the statement could mislead.
2. U Save TV acknowledged that they did not have enough evidence to substantiate the claim. 3. U Save TV maintained that house dust mites were a frequent cause of allergic reactions and that one of their favourite locations was bedding. They claimed that house dust mites would not, or perhaps could not, live in silk. They added that, provided the rest of the bedding was washed regularly to keep it “mite-free”, that source of allergy could be controlled. 4. U Save TV maintained that silk-filled clothing was used by explorers in the Amazon jungle and in Alaska because of the silks natural properties. But they conceded that the claim was merely a suggestion and that it could apply also to other types of bedding. 5. U Save TV submitted no evidence and said the claim had been removed from the ad.
Assessment
1. Upheld
The ASA considered that evidence from a study on specially treated silk clothing could not be extrapolated to a duvet that was filled with a diVerent type of silk and had a cotton casing. We considered that the claim was misleading.
2. Upheld
We noted that no evidence was presented to show that house dust mites were unable to live in silk-filled duvets or that a cotton-cased duvet would produce the improvements described in the study. We considered that the claims were misleading. allergy: evidence 335
3. Upheld
Because no evidence was presented to show that house dust mites were unable to live in silk filled duvets and because the duvet had a cotton casing, we considered that the claim was misleading.
4. Upheld
We noted no evidence was presented to support the claim that the duvet would adjust to the body’s temperature or be warm in the winter and cool in the summer. We considered that the claims were misleading.
5. Upheld
We welcomed the broadcasters action but nevertheless considered that the claims were misleading. We concluded that the ads breached rules 5.1 (Misleading advertising) and 5.2.1 (Evidence) of the CAP (Broadcast) TV Advertising Standards Code.
Action
The ads must not be shown again in their present form and the products should not be advertised without adequate substantiation for the claims made.
Sharp Electronics (UK) Ltd Publish Date: 6 October 2004 Media: National press Sector: Household Public complaint from: London
Complaint
Objection to a national press advertisement that was headed “I suVered allergies for 15 years. It only took two months to feel the diVerence”. It claimed “. . . Sarah has a job she loves . . . But since being a small child herself, she’d suVered badly with asthma and hay fever. Over the years she had learned that the most likely triggers were pollen, pets, and most especially, airborne mite allergens. Apart from irritation of the eyes, nose and throat, the severity of her allergy caused her actue breathing diYculties. Particularly at night, when it would become hard to get the restful sleep she needed to face the next busy day. As a result Sarah gave a trial to the new Sharp Healthcaire FU-40SEK Plasmacluster air purifier . . . In as short a time as two months she began to notice a diVerence in her life. The severity of her symptoms was reduced and she was not able to sleep soundly right through the night . . . Introducing Plasmacluster Ion Technology. A scientific solution to airborne allergens . . . After lengthy research and development they [experts in the field of molecular biotechnology] have recently verified that they had identified a pro-active way to deactivate airborne mite allergens*, one of the most common asthma triggers . . . The Sharp Healthcaire air purifier is the first device to incorporate a Plasmacluster Ion generator, the key to this revolutionary breakthrough in anti-allergen technology. This produces streams of positive and negative ions—which are natural components of healthy air—that quickly bond with water molecules, known as cluster ions. When these cluster ions are released into a room they actively seek out and surround airborne mite allergens. A chemical reaction takes place and the allergen is rendered harmless, robbed of its ability to provoke an allergic response even if breathed in . . . Plasmacluster Ion Technology is not in itself a cure for Asthma or other allergies. But for suVerers like Sarah, it may mean that they can now breathe in a purer air that isn’t laden with the active allergens that have caused them years of misery”. The complainant, who believed the product did not aVect dust mite allergens, challenged whether the device benefited people who suVered from dust mite allergies. Codes Section: (Ed 11: 3.1; 7.1; 50.1) 336 allergy: evidence
Adjudication
Complaint upheld The advertisers said the device had been independently tested in Japan; they sent a press release that detailed the test results. They said, before the device was marketed in the UK, trials on allergy suVerers had been conducted by a specialist communication company on their behalf; they said the feedback from those trials had been mainly positive. The advertisers said they had selected two of the trials to form the basis of their advertising and sent a copy of one of the completed questionnaires from an allergy suVerer. The advertisers asserted the device had been awarded a “Seal of approval” by the British Allergy Foundation and that two professors, who were specialists in the field, had stated the eVectiveness of the device in combating the triggers that caused allergic reactions. The Authority took expert advice. It understood that the advertisers’ evidence showed the device provided eVective air filtration and that the additional plasma cluster technology could inactivate allergens in the air. It nevertheless understood that, in the absence of a rigorously designed clinical study, corrected for any placebo eVect, the eYcacy of the device for providing actual clinical benefit to allergy suVerers was unproven. The Authority considered that the advertisement implied the device would rid the air in people’s homes of virtually all airborne allergens and help those with medical conditions such as asthma. The Authority noted the results of the trials conducted on behalf of the advertisers, but considered that the results of those trials were not suYcient to substantiate that implication. In the absence of product-specific, clinically controlled trials on suVerers to prove the eYcacy of the advertised product, the Authority concluded that the advertisement was misleading. It told the advertisers not to repeat the advertisement and advised them to consult the CAP Copy Advice team before advertising the device again.
Samsung Electronics UK Ltd Publish Date: 16 June 2004 Media: Magazine Sector: Household Industry complaint from: Wiltshire
Complaint Dyson Ltd objected to a trade magazine advertisement, for a washing machine, that was headlined “larger drum—less washing time”. Text stated “EVective, eYcient and allergy free washing from Samsung . . . This powerful washing machine is not only a first for its size but also for its innovation. The unique Detergent Dissolver System diVuses the detergent faster and more eVectively before its reaches the wash, minimising the residue left on your clothes which can cause skin irritation. And the impressive 7.5 kg load capacity, the largest in a standard UK size machine, ensures fewer loads to complete your washing . . .”. The complainants challenged whether: 1. the advertisement, especially the claims “larger drum—less time washing” and “not only a first for its size, but also for its innovation”, misleadingly implied that the advertisers’ machine had a larger drum than competitors’ machines; 2. the advertisement, especially the claims “larger drum—less time washing” and “not only a first for its size, but also for its innovation”, misleadingly implied that the advertisers’ machine washed more quickly than competitors’ machines and 3. the claim “allergy free washing” was misleading, because they understood that the advertisers’ machine performed poorly and less well than the Dyson CR01 on the IEC test, which measured the level of detergent left in the final rinse water. Codes Section: (Ed 11: 3.1; 7.1; 19.1)
Adjudication
1. Complaint not upheld The advertisers stated that the advertised washing machine was called Bigwash, because it had a larger load capacity and could wash large items such as duvets, towels and curtains. They stated that the Samsung Bigwash had a drum volume of 60 litres and a capacity of 7.5 kg; they said the 7.5 kg capacity was a first for its size and innovation, because no other brand provided that much washing capacity under European standard dimensions of 60 cm width, 60 cm depth and 82 cm height. They argued that they had never claimed that their allergy: evidence 337 washing machine’s drum volume was the largest, merely that its load capacity was the largest for the European standard depth of 60 cm. The advertisers asserted that the complainants’ machine, the Dyson CR01, which had a depth of 71 cm, was oversized compared with European standard dimensions. The Authority noted although the Dyson CR01 had a drum volume of 78 litres, its load capacity was less than that of the advertised machine. It also noted the Dyson CR01 had a depth that was greater than the standard UK size machine. The Authority considered that the advertisement made clear the 7.5 kg load capacity of the advertised machine was the largest for a standard size machine. Because it noted the advertised machine could wash a larger load compared with other washing machines, including the complainants’ machine, the Authority concluded that the advertisement was not misleading on that point.
2. Complaint not upheld The advertisers stated that a comparative test had shown that the Samsung Bigwash had a cycle time of 98 minutes (mins) compared with 118 mins for Miele, 124 mins for Bosch and Siemens and 145 min for Zanussi; they had not included the Dyson machine in the test because it was in a diVerent size category. The advertisers asserted that no other brand had a shorter cycle time for a 7.5 kg load. The Authority noted, although it had a cycle time of 88 mins, the Dyson CR01 was larger than the standard size. The Authority noted the advertisement stated “. . . the impressive 7.5 kg load capacity . . . ensures fewer loads to complete your washing . . .”. It considered the consumers would infer from the advertisement that, because the advertised machine could wash heavier loads than other machines, they could complete their washing in fewer loads and thus spend less time washing, not that the advertised machine had a shorter cycle time compared with competitors’ machines. The Authority concluded that the advertisement was not misleading on that point.
3. Complaint upheld The advertisers asserted that the Bigwash programs on the advertised machine, which no other manufacturer provided, focused on low detergent residues. They stated that WFK in Germany had conducted comparative tests to measure detergent residues; they said the results showed that the Samsung Bigwash 6 kg produced less detergent residue than Bosch, Hoover, Whirlpool and the Dyson CR01 washing machines. The advertisers asserted that, as well as the Bigwash programs, the Samsung Bigwash 7.5 kg had a “Detergent Dissolver System” to minimise detergent residue on laundry; the detergent powder was full dissolved and liquidised quickly to minimise residue that was not dissolved completely during washing. They asserted that their machine also had a “Shower Spinning” function that sprayed water onto the laundry during the spin cycle, thus helping to reduce skin problems. They said to ensure “allergy free washing” for sensitive people, their machine had a “Rinse Selection” option, which enabled consumers to increase the rinse cycle up to five times; they asserted that no other European brand had that feature. The Authority noted the results of the detergent residue tests and the features of the machine that the advertisers asserted reduce detergent residue. It nevertheless considered that the advertisers had not sent suYcient substantiation, including the results of clinical trials, to show that the advertised machine could provide a significant benefit to allergy suVerers. The Authority concluded that the claim was misleading and advised the advertisers to amend it with help from the CAP Copy Advice team.
Medivac Healthcare Ltd Publish Date: 19 February 2003 Media: Leaflet Sector: Health and Beauty Public complaint from: Berkshire
Complaint Objection to a leaflet for products for people with asthma, eczema and rhinitus. The leaflet stated“. . . Swiss mountain air quality for your home or oYce. How does the Airwasher work? The new Swiss-designed Medivac Airwasher literally washes the air you and your family will breathe . . . The Airwasher has also been designed to help breathing diYculties during the drier months of the year when relative humidity levels are reduced . . . The modern design of the Medivac Airwasher will look good in any home or oYce. This appliance is strongly recommended for adults and children whose medical condition is influenced by exposure to common allergens, from dust mites, cats, traYc or any of the many airborne particles created by our modern lifestyles . . . Medivac has satisfied the United Kingdom’s [sic] HM Customs & Excise that Medivac Healthcare products are of such medical benefit to adults and children with asthma, eczema or rhinitus, that such individuals may purchase Medivac products free from Value Added Tax . . . The Airwasher is designed solely to protect adults and 338 allergy: evidence children from airborne allergens . . . which can trigger asthma, rhinitis or eczema . . .”. The complainant challenged the eYcacy of the device. Codes Section: (Ed 10: 3.1; 7.1; 50.1; 50.3)
Adjudication
Complaint upheld The advertisers said their airwasher was an allergen avoidance product; they argued that the eYcacy of allergen avoidance products had been proven by medical research institutions. They claimed that their product had two main features: it washed and it humidified air, both without the use of filters. The advertisers argued that temperature, air purity and moisture content of the air were all important factors in the maintenance of an ideal room climate. They explained how their product worked. The advertisers sent various references referring to studies about asthma prevention and the links between allergen exposure and respiratory allergy. They said they had no plans to promote the product again. The advertisers commented that they had received only one complaint about the product. The Authority considered that the leaflet implied the product would rid the air in people’s homes of virtually all pollutants and help those with medical conditions such as asthma. In the absence of results of product-specific, clinically controlled trials on suVerers to show the product worked as advertised, the Authority told the advertisers not to repeat the advertisement and advised them to consult the Committee of Advertising Practice Copy Advice team before advertising again.
Letter from the British Occupational Health Research Foundation We do not have any research relating to non-occupational allergies and their impact on work and attendance. However, we are able to provide evidence pertaining to a specific allergy ie; occupational asthma from: Newman Taylor AJ, Nicholson PJ (Editors). Guidelines for the prevention, identification and management of occupational asthma: Evidence review and recommendations. British Occupational Health Research Foundation. London 2004. The strength of evidence is identified as: *** Strong evidence—provided by generally consistent findings in multiple, high quality scientific studies. ** Moderate evidence—provided by generally consistent findings in fewer, smaller or lower quality scientific studies. * Limited or contradictory evidence—provided by one scientific study or inconsistent findings in multiple scientific studies. We note that your letter refers to “The Provision of Allergy Services” Department of Health July 2006. One of the editors of the BOHRF Evidence Review was a member of the National Allergy Advisory Group associated with that review.
Defining the Problem:
What is asthma? Asthma is a condition of chronic inflammation of the airways, characterised by widespread airflow limitation that is reversible, either spontaneously or with treatment over short periods of time. The inflammation results in hyper-responsiveness of the airways to many stimuli eg cold air, cigarette smoke, exercise, etc and in the clinical setting to methacholine and histamine. Symptoms include wheeze, cough, shortness of breath and chest tightness and are often worse at night or in the early morning. Work-related asthma occurs when there is an association between symptoms and work. The two diVerent types of work-related asthma are: — work aggravated asthma, ie pre-existing or coincidental new onset adult asthma which is made worse by non-specific factors in the workplace, and — occupational asthma ie adult asthma caused by workplace exposure and not by factors outside of the workplace. Occupational asthma is subdivided into: — allergic occupational asthma characterised by a latency period between first exposure to a respiratory sensitiser at work and the development of hypersensitivity symptoms, and allergy: evidence 339
— irritant-induced occupational asthma that occurs typically within a few hours of a high concentration exposure to an irritant gas, fume or vapour at work. The evidence provided hereafter relates exclusively to allergic occupational asthma.
What is and what is not known about the origins and progression of occupational asthma? Four risk factors have been identified including the predisposing factors of atopy and genetic predisposition, the causative factor of exposure to an agent at work and the contributing factor of cigarette smoking. Atopy is a state characterised by the propensity to produce specific immunoglobulin IgE on ordinary exposure to common allergens in the subject’s environment. *** Atopy increases the risk of developing occupational asthma caused by exposure to many high molecular weight agents that induce the production of specific IgE antibodies. ** Some genes may predispose to occupational asthma for some agents. Several hundred workplace agents are reported to cause occupational asthma. Those that induce allergic occupational asthma can be divided into those of high and low molecular weight. The former are usually proteins and appear to act through a type I, IgE associated hypersensitivity. Whilst some low molecular weight chemicals are associated with specific IgE antibodies, this is not the case for the majority. *** The risk of sensitisation and occupational asthma is increased by higher exposures to many workplace agents. *** The most frequently reported agents include isocyanates, flour and grain dust, colophony and fluxes, latex, animals, aldehydes and wood dust. *** The workers most commonly reported to surveillance schemes of occupational asthma include paint sprayers, bakers and pastry makers, nurses, chemical workers, animal handlers, welders, food processing workers and timber workers. ** The workers reported from population studies to be at increased risk of developing asthma include bakers, food processors, forestry workers, chemical workers, plastics and rubber workers, metal workers, welders, textile workers, electrical and electronic production workers, storage workers, farm workers, waiters, cleaners, painters, plastic workers, dental workers and laboratory technicians. ** Cigarette smoking can increase the risk of developing occupational asthma with some sensitising agents. ** Occupational rhinitis and occupational asthma frequently occur as co-morbid conditions in IgE associated occupational asthma. Occupational rhinitis is a risk factor for the development of occupational asthma, especially for high- molecular-weight sensitisers: ** Rhino-conjunctivitis is more likely to appear before the onset of IgE associated occupational asthma. * The risk of developing occupational asthma is highest in the year after the onset of occupational rhinitis. Generally, occupational asthma is reported to have a poor prognosis and to be likely to persist and deteriorate unless identified early and managed eVectively. *** The symptoms and functional impairment of occupational asthma caused by various agents may persist for many years after avoidance of further exposure to the causative agent.
Why does the UK in particular have such a high prevalence of occupational asthma? The reported prevalence of occupational asthma in the UK is similar to other westernised countries. *** Occupational factors are estimated to account for 9–15 per cent of cases of asthma in adults of working age, including new onset or recurrent disease. *** The annual population incidence of occupationally related asthma ranges from an estimated 12 to 170 cases per million workers with an estimated mean of 47 cases per million workers. 340 allergy: evidence
What gaps exist in establishing the overall disease burden of occupational asthma and what are the barriers to filling the gaps?
One of the two reporting schemes (SWORD) is voluntary and the other (RIDDOR) requires patient consent. This leads to under-reporting in both. * The population incidence of occupational asthma may be underestimated by as much as 50 per cent.
Treatment and Management
What is the effect of current treatments on the natural history of occupational asthma?
The pharmacological management of occupational asthma is no diVerent to that of any case of adult asthma. What diVers is the occupational health management. A single small randomised-controlled trial has examined the eVect of inhaled corticosteroids on the recovery from occupational asthma after cessation of exposure. Small but statistically significant improvements in some symptoms, peak flow and quality of life were reported. Workers who remain in the same job and continue to be exposed to the same causative agent after diagnosis are unlikely to improve and symptoms may worsen.
What is the evidence base for pharmacological and non-pharmacological management strategies?
Complete avoidance of exposure may or may not improve symptoms and bronchial hyper-responsiveness. Both the duration of continued exposure following the onset of symptoms and the severity of asthma at diagnosis may be important determinants of outcome. Early diagnosis and early avoidance of further exposure either by relocation of the worker or substitution of the hazard oVer the best chance of complete recovery. *** The likelihood of improvement or resolution of symptoms or of preventing deterioration is greater in workers who have no further exposure to the causative agent. ** The likelihood of improvement or resolution of symptoms or of preventing deterioration is greater in workers who have relatively normal lung function at the time of diagnosis. ** The likelihood of improvement or resolution of symptoms or of preventing deterioration is greater in workers who have shorter duration of symptoms prior to diagnosis. ** The likelihood of improvement or resolution of symptoms or of preventing deterioration is greater in workers who have shorter duration of symptoms prior to avoidance of exposure.
Is the level of UK research into occupational asthma adequate?
BOHRF produced the world’s first evidence based guidelines for occupational asthma hence the UK is seen as a world leader in this area along with Canada, France and Spain. More research has been identified by the Health & Safety Executive examining in particular worker behaviour. Further research should be undertaken to assess the impact of evidence based guidelines and how their impact might be improved, and the most suitable components and frequency of health surveillance.
Government Policies
How effective have existing Government policy and advice been in addressing the rise in occupational asthma?
The Health and Safety Executive (HSE) estimate that 1,500 to 3,000 people develop occupational asthma each year. HSE estimates that the costs to society of new cases of occupational asthma are up to £1.1 billion over 10 years. HSE set up an Asthma Project Board in 2000 to help it reduce the incidence of occupational asthma by 30 per cent over 10 years. Data suggests that the incidence has reduced in the last three years. allergy: evidence 341
Patient and Consumer Issues
What impact does occupational asthma have on quality of life of patients and their families? There is consistent evidence that: ** Approximately one third of workers with occupational asthma are unemployed up to six years after diagnosis. ** Workers with occupational asthma suVer financially.
What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed sufferers? We believe that the BOHRF reviews and their practical lay guidance for the public, managers and safety professionals serve as a good model for communicating important messages as both hard copy and on the internet. Furthermore leaflets and internet based advice aimed at primary care staV serves to increase awareness to lead to earlier identification of cases. Only one in eight of the UK workforce has access to comprehensive occupational health support. Making access more available is a key opportunity. As well as increasing the numbers of competent human resource, it would be useful to provide access to better online support, eg by making respiratory questionnaires accessible online.
Are current regulatory arrangements for private clinics satisfactory? Any clinician may open and oVer an occupational health service. Competence should be better defined and relate to qualifications and revalidation of providers. Since many cases of occupational asthma first report to primary care, there is a need for better training in occupational medicine for GPs. 31 October 2006
Letter from the British Thoracic Society Whereas the British Thoracic Society is strongly supportive of the overall direction ofa strengthening of allergy services (both clinical and research) within the UK we have little if any specific numerical data of our own. We recognise allergy to be an increasing workload of primary care physicians, respiratory physicians, ENT specialists and dermatologists as well as specialised tertiary allergy referral centres. Respiratory physicians manage many patients with allergic associated diseases (such as asthma, occupational asthma, rhinitis, allergic alveolitis etc) and aspects of allergy are included in the specialty training curricula. 1. We have formally supported the concept proposed by the BSACI that there should be an Allergy clinic staVed by Specialist Allergists or Immunologists within each teaching hospital and that these should be equitably spread throughout the UK. 2. From the available data we have seen and on the BSACI website for the geographical location of the present Allergy clinics the present capacity and potential shortcomings of the tertiary Allergy/immunology services are unclear. 3. The exact number of patients with allergic conditions for example hay fever, asthma, eczema and food allergy/intolerance who are satisfactorily dealt within Primary care, Respiratory, ENT, stroenterology and Dermatology clinics without the need for referral to tertiary care is large, but the BTS has no figures for such workload within any specialty. 4. However within our own specialty the expenditure of asthma medications such as inhaled steroids are amongst the largest single drug spends withinthe NHS. 5. Undoubtedly there is a small but very important group of patients that our members would wish to refer to specialist tertiary allergy services and who currently get poor access by the limited number of such clinics and long waiting times but again we do not have exact figures to support this. 6. We hope that your committee would explore the current and future real and potential threats to the existing allergy services throughout the UK. Examples would be retirement of senior staV; a necessity for growth in training posts, capacity for training general practitioners and consultants in organ based specialties such as 342 allergy: evidence our own and of course research which regrettably has a history of being under funded as far as respiratory medicine is concerned. 7. It would also be helpful to develop an ideal model for an allergy centre as far as specific staYng and support ie Consultants, SpR’s, Specialist Nursing, Secretarial support and the costing thereof. One could then test the present availability against the ideal model. 24 October 2006
Letter from Dr A T Clark, Consultant Paediatric Allergist and Dr P W Ewan, Consultant Allergist House of Lords Science and Technology Committee: Allergy inquiry We thought it might be helpful to put in context the recent media coverage, including a slot on “Today”, on severe food allergy, as it gave a misleading impression. This followed an article in the British Medical Journal (BMJ) by Professor Colver, titled “Are the dangers of childhood food allergy exaggerated?”. The message was that they are exaggerated. This debate was based on data published by Professor Colver in 2002 (Archives Disease of Childhood). This was criticized by 2 groups (of international experts in childhood allergy), published later in the same journal. Similarly there were published criticisms of the recent BMJ article. This highlights two issues. There is debate and we do not have enough data to inform routine clinical decisions; so high quality clinical research to answer basic questions in allergy is much needed. Second, the author is commenting from the position of a non expert in allergy (his expertise is in community child health), and selectively quotes from the literature. Colver’s original study was poorly designed and biased, by both failing to recruit children from major allergy centres and setting inappropriately restrictive criteria for inclusion (for example a child requiring one injection of adrenaline is not included—yet a child would usually be very ill before adrenaline was given). Colver’s conclusions and much publicized opinions are therefore based on flawed study design and misinterpretation of the findings. An analysis of our data on 1,500 children with nut allergy revealed a severe reaction rate of 1.93 per 100,000 population per year, a figure 10 times that suggested by Colver for all foods. Media publicity of poorly conducted studies is misleading. 7 October 2006
Memorandum by Coeliac UK
1. Introduction
1.1 Coeliac UK is the only national charity supporting people with coeliac disease. It was formed in 1968 as The Coeliac Society to provide support and advice to people with coeliac disease. 1.2 Coeliac disease is a life-long auto-immune disease caused by an intolerance to gluten. Left untreated it can lead to life-threatening malnutrition or other serious complications such as osteoporosis and bowel cancer. It can only be controlled by a strict gluten-free diet for life. Therefore, in identifying and managing the condition the issues are comparable to those surrounding allergies and other intolerances. 1.3 Studies show that 1 in 100 people in the general population have coeliac disease but only 1 in 8 will have been clinically diagnosed. Of these Coeliac UK has over 70,000 people as members. It is the oldest and largest coeliac society in the world; and a leading source of information on coeliac disease. 1.4 Besides supporting our members and the broader coeliac community, the charity provides information to healthcare professionals who use our services to provide information to their patients. 1.5 We have a Helpline telephone service run by registered dietitians providing advice and support to members, health care professionals, food manufacturers and the general public. 1.6 We also work closely with the leading gluten-free food manufacturers and retailers to provide advice and promote choice and availability. 1.7 We are also providing funding for invaluable research into the causes, nature and treatment of coeliac disease. allergy: evidence 343
2. Defining the Problem
What is the definition of food allergy? 2.1 An allergic reaction to a food can be described as an adverse reaction by the body’s immune system to the ingestion of a food that in the majority of individuals causes no adverse eVects. Allergic reactions to foods vary in severity and can be potentially fatal. In food allergy the immune system does not recognise as safe a protein component of the food to which the individual is sensitive (such as some peanut proteins). This component is termed the allergen. The immune system then typically produces immunoglobulin E (IgE) antibodies to the allergen, which trigger other cells to release substances that cause inflammation. Allergic reactions are usually localised to a particular part of the body and symptoms may include asthma, eczema, flushing and swelling of tissues (eg the lips) or diYculty in breathing. A severe reaction may result in anaphylaxis (as with severe peanut allergy) in which there is a rapid fall in blood pressure and severe shock. Food allergy is relatively rare, aVecting an estimated 6–8 per cent of children and 1–2 per cent of adults, and is often wrongly used as a general term for adverse reactions to food.
What is the definition of food intolerance? 2.2 Food intolerance is the general term used to describe a range of adverse responses to food, including allergic reactions (eg peanut allergy or coeliac disease), adverse reactions resulting from enzyme deficiencies (eg lactose intolerance or hereditary fructose intolerance), pharmacological reactions (eg caVeine sensitivity) and other non-defined responses. Food intolerance reactions are usually reproducible adverse responses to a specific food or food ingredient, which can occur whether or not the person realises they have eaten the food. 2.3 In any consideration of allergies and intolerances, however, coeliac disease should also be considered as it aVects 1 in 100 of the population and people with the disease face the same issues and challenges as people with allergies or food intolerances. These include the diYculties of obtaining early accurate diagnosis, the need to maintain a nutritional diet, management of that diet, access to aVordable food alternatives, the safe selection of food, and the dangers of cross-contamination in cooking and food preparation.
Incidence and prevalence 2.4 Studies have shown that the prevalence of coeliac disease in the general population is 1 in 100. This seems to be true across Europe. It may appear to be raising in comparison to earlier studies but it is more likely that it is simply better recognised than in the past and that there is a greater awareness of coeliac disease. The development of screening tools in antibodies tests specific to coeliac disease (i.e endomysial antibodies— EMA- and tissue transglutaminise -tTGA) have improved diagnosis rates in recent years.
Socio-economic impact 2.5 It is diYcult to assess the overall burden of coeliac disease due to the absence of recorded information on diagnosis rates. There is a need for a central register of coeliac disease patients. 2.6 As a health problem, coeliac disease has an impact on both the individual and the community because of high prevalence and long-term complications due to late diagnosis. The development of osteoporosis or bowel cancer therefore has an impact for the individual, the community and the health service. Even in the short- term the absence of diagnosis has a socio-economic impact. 2.7 According to an independent study commissioned by Coeliac UK in 2006, just under half (46 per cent) of people with coeliac disease who had been wrongly diagnosed believed that their job or career suVered due to their condition prior to diagnosis.
3. Treatment and Management 3.1 Better understanding and greater familiarity is needed among GPs for coeliac disease to be diagnosed earlier. The disease needs to be recognised before the patient can be treated. Coeliac disease needs to be higher in the GP’s consciousness and earlier testing is essential to diagnose or eliminate coeliac disease from diagnosis early on. 344 allergy: evidence
3.2 GPs need to recognise that, once diagnosed, patients need to be referred to a registered dietician to help advise on the management of their diet. In the YouGov study of diagnosis conducted in February 2006, 43 per cent of respondents were not referred to a dietician despite the fact that the condition can only be controlled by following a strict gluten-free diet. 3.3 Dieticians and other healthcare professionals, namely GPs, need continuing professional development to ensure that they are aware of the current guidelines on coeliac disease and information on the gluten-free diet. 3.4 A survey conducted by Coeliac UK of registered dieticians showed that there is a wide variation nationally in the level of provision of dietetic expertise for patients with coeliac disease. The current level of provision is in the region of one third of what would be required to provide diagnosed coeliacs in the UK with basic support and annual review.
4. Government Policies 4.1 There is a continuing cost to the health service in repeat visits to their GPs by people with undiagnosed coeliac disease. 4.2 Furthermore, left untreated or undiagnosed it can lead to more serious complications such as bowel cancer and osteoporosis which will require a bigger drain on health service resources in the longer term. 4.3 Coeliac UK recognises the competing demands upon health service resources and budgets but coeliac disease is a disease that is easily controllable once diagnosed. It is a disease that can potentially be self-managed if diagnosed early enough in life. 4.4 Government policy needs to acknowledge the scale of coeliac disease’s impact across a large segment of the population. Policy also needs to take into account the potentially serious nature of the disease, the cost in financial terms and suVering for the undiagnosed and therefore recognise the importance of early diagnosis. In particular measures could be taken to: — address the lack of awareness of the disease and to provide a framework to ensure that GPs receive the appropriate training and resources. This would enable them to better recognise and more accurately diagnose the disease and thus increase the speed of diagnosis and improve diagnosis rates. — and to provide ongoing training to enable GPs to give better care in the community for patients with coeliac disease.
Importance of prescriptions 4.5 As coeliac disease can only be controlled through a gluten-free diet, which restricts intake of the staple foods, it is essential that patients with coeliac disease are able to buy gluten-free food substitutes for the staple foods like bread, flour and pasta in the diet. 4.6 Many gluten-free foods and food ingredients are more expensive than their gluten-containing alternatives. To many people on low incomes, especially the vulnerable young and old, the cost of some gluten-free foods could be prohibitive. For example:
Comparative costs Normal price Gluten-free price White loaf of bread (400g) 35p £2.49 Plain white flour (250g) 22p £1.99 Penne pasta (500g) 31p £3.20 * This is based on a comparison between Dietary Specials gluten-free products available in shops and Tesco’s own brand. 4.7 The Department of Health provides guidance which enable coeliac patients to receive prescriptions to obtain gluten-free food and so maintain a healthy diet. 4.8 Recently, in an eVort to make cost-savings, some Primary Care Trusts have sought to restrict the number of gluten-free prescriptions that are being issued and have issued guidance to GP Surgeries to cut down on the number of prescriptions or restrict them to staples. This may include bread, flour and bread mixes but may not include pasta which to many people these days (particularly with children) is now a staple. There has been an inconsistency in the policies or recommendations put forward by PCTs across the country. allergy: evidence 345
Food labelling policy
4.9 In recent years we have seen great improvements in the labelling of food containing gluten particularly in light of the recent implementation of the European Commission Directive on allergen labelling (2003/89/EC). This is a great advance and Coeliac UK has been working closely with the Food Standards Agency. 4.10 However, for many people there is still some confusion as to what the labelling means. Coeliac UK owns the trademark of the Crossed Grain symbol which manufacturers can licence to brand their products to indicate that they are gluten-free. The Crossed Grain symbol is globally recognised and provides a reassurance to people with coeliac disease that the product they are buying is gluten-free and safe to eat.
5. Patient and Consumer Issues
The problem for the patient
5.1 The first problem for the patient with coeliac disease is the lack of knowledge at primary care level. GPs do not always recognise coeliac disease when confronted with the symptoms. It is often diagnosed as some other ailment and the patient frequently finds themselves making repeated visits to their GP as their symptoms persist. This causes both distress to the patient (as coeliac disease can be a debilitating illness if left untreated) and a cost to the health service in terms of the repeated visits to the GP. 5.2 A survey conducted for Coeliac UK shows that one third of coeliac patients visit their GP seven or more times before receiving a correct diagnosis. One fifth were only diagnosed after everything else had been “ruled out” and two fifths were not tested for coeliac disease until a year after first visiting their GP with the symptoms.
Quality of life
5.3 People with coeliac disease can experience bloating, exhaustion, diarrhoea, anaemia, headaches, weight- loss, mouth ulcers and skin complaints. It can be a distressing and debilitating illness. 5.4 In the recent survey of members undertaken by IPSOS MORI for Coeliac UK 56 per cent considered coeliac disease to have limited their life to a “fair amount or a great deal”. This was also borne by a survey undertaken by YouGov for Coeliac UK, which showed that among a representative sample of diagnosed coeliacs 59 per cent of respondents believed that their social life suVered as a result of their illness prior to diagnosis. 5.5 Furthermore, in the YouGov survey 68 per cent of men and 52 per cent of women felt that before diagnosis their condition had left them too tired or ill to participate in sports or exercise. 5.6 One fifth believed their sex life suVered before diagnosis.
How to educate the public and improve quality of information available to patients and undiagnosed sufferers
5.7 The Government could generally help to raise awareness of coeliac disease by: — providing better training and resources for GPs; — ensuring that healthcare professionals are aware of recent advances in diagnosis and management; and — taking measures to encourage better provision of gluten-free meals in institutions such as schools, hospitals and care homes.
6. Conclusion
6.1 We welcome the Select Committee’s decision to investigate allergies and allergic diseases. We hope that it will broaden its scope to consider the policy implications for coeliac disease which is a diet-managed disease where early diagnosis and safe selection of food are key issues. 346 allergy: evidence
6.2 Coeliac disease is comparable to allergies and intolerances in its impact on the individual, their wider community and the socio-economic impact. 6.3 With 1 in 100 of the population believed to have the disease; with currently only 1 in 8 diagnosed; and in view of the possible serious long-term complications that can arise from a lack of diagnosis the identification, diagnosis and treatment of coeliac disease has implications for policy and resources that we hope the Select Committee will consider.
References (not printed)
3 November 2006
Memorandum by the Faculty of Homeopathy
1. Background
1.1 The Faculty of Homeopathy was incorporated by an Act of Parliament 1950 and represents statutorily registered healthcare professionals who have trained in and integrate homeopathy into their practice. The majority of Faculty members are doctors (specialists working in the five NHS homeopathic hospitals, GPs or independent practitioners) though there are also growing numbers of nurses, pharmacists, dentists, podiatrists and vets. 1.2 Homeopathy is the only complementary therapy to have been part of the NHS since its inception in 1948. Today there are five NHS homeopathic hospitals—Bristol, Glasgow, Liverpool, London and Tunbridge Wells. These are consultant-led services, which take referrals from GPs and specialists and are staVed by doctors who have trained and qualified in homeopathy and other CAM (Complementary and Alternative Medicine) therapies such as acupuncture. 1.3 Clinical outcome studies from the hospitals consistently demonstrate a high level of patient satisfaction with patient-reported improvement rates of over 70 per cent even though many of the patients referred have not improved with the conventional treatment they have usually tried at length before coming to homeopathy.
2. The Homeopathic Treatment of Allergies
2.1 Homeopathy In homeopathy there are a number of therapeutic strategies for the treatment of allergic disorders. These are commonly termed “local”, “constitutional” or “miasmatic” strategies. Local prescribing is a strategy based on the patient’s actual allergic symptoms. The advantage of this strategy is that it can be achieved in a standard GP appointment or even through self-prescribing. Constitutional prescribing is based on a more in-depth consultation which takes into consideration the patient’s allergic symptoms and, additionally, their unique patterns of coping with any disease. Miasmatic prescribing is based on an elaboration of the patterns of allergic disease which can be seen to run through certain whole families. This approach can be particularly appropriate in complex allergic conditions. 2.2 Isopathy Isopathy is similar to homeopathy but the main diVerence is that the treatment is selected solely on the basis of the patient’s proven allergies (as shown, for example, by skin testing). It involves giving a patient a substance to which they are allergic in a homeopathic potency, usually orally, for a short course of a few days in order to reduce the allergic response. All the common allergens such as pollens and dusts are available in potentised form from the specialist homeopathic pharmacies and it is also possible to have customised medicines made. 2.3 All of these approaches involve prescribing homeopathic or isopathic medicines which are safe, not addictive and have no side eVects. However in some cases there may be a temporary worsening of symptoms immediately after the patient receives the treatment—the phenomenon known as “aggravation”. This does not entail any risk of anaphylactic shock. Treatment options are individually tailored and rely on sensitive history-taking and a flexible response by the practitioner, including careful consideration of diet and lifestyle. allergy: evidence 347
3. Why Patients Choose Homeopathy
3.1 The homeopathic approach diVers from conventional medicine in that rather than suppressing the allergic symptoms, the medicines stimulate the body’s ability to cope with exposure to the allergens. The benefits are therefore longer-lasting and free from the side eVects associated with conventional treatments. A homeopathic medicine taken before the hay fever season begins can act prophylactically protecting the patient and so reducing the need for medicines such as antihistamines. 3.2 Many patients and doctors are concerned about the long-term use of conventional drugs such as corticosteroids and anti-histamines and for some patients a conventional approach has not helped so they seek more holistic advice and care.
4. Specialist Allergy Services at the Homeopathic Hospitals
4.1 All the NHS homeopathic hospitals receive referrals for patients with allergy problems. Glasgow and London have special allergy clinics. 4.2 Glasgow Homeopathic Hospital, North Glasgow University Hospitals NHS Trust Dr Jacqueline M Mardon MBBS MPhil MRCGP MFHom 4.2.1 Allergy is a frequent reason for people to be referred to Glasgow Homeopathic Hospital by their medical practitioner. The Allergy Clinic has been running for many years and is funded as 26 clinical sessions/year. Originally set up on a research basis, it is currently run by one experienced medical practitioner who is on the Faculty of Homeopathy specialist register and who regularly attends conventional medical allergy seminars and updates. 4.2.2 Children and adults are accommodated in either a general out-patient clinic or, in particular if there is a strong indication of atopy or a complicated history such as anaphylaxis or multiple sensitivities, in the specialist allergy clinic. Sometimes a patient is referred elsewhere in the homeopathic service from the clinic, for example for in-patient care. A wide range of allergic conditions and morbidity is seen. 4.2.3 The clinical approach includes an emphasis on careful history taking and assessment may include skin- prick testing to a wide range of allergens, performed in the clinic. Treatment is with a variety of methods: homeopathic constitutional prescribing, symptom alleviation using homeopathic remedies and isopathy which can often be prophylactic or curative where specific allergens are identified. Advice about preventative measures and a supportive approach in complex cases in particular is also a mainstay of treatment. 4.2.4 Using this approach, one is able to address complex emotional issues which are so often involved (aetiologically and as a result of the disease). Patients often find it easier to accept advice about allergy from the homeopathic hospital, which can steer them away from the more extreme (and expensive) fringes of untested alternative treatments. This can be of particular benefit with food sensitivities and allergies or multiple sensitivities. 4.3 Royal London Homeopathic Hospital, University College London NHS Trust Dr Saul Berkovitz MRCP MFHom MCPP 4.3.1 Allergy clinics at the RLHH are run by a consultant physician with a postgraduate diploma in Allergic Disease from the University of Southampton. There are three consultant sessions per week and two clinical assistant sessions. Classical allergic diseases are managed with avoidance advice, conventional treatment where appropriate, dietary advice, homeopathic medication, Western Herbal Medicine, and also (uniquely in the NHS) with a form of desensitisation treatment called enzyme-potentiated desensitisation (EPD). The clinic is also one of the very few centres able to eVectively manage patients with “food intolerance” in all its manifestations. 4.3.2 EPD is a therapeutic technique in which low dose allergens (in concentrations of 10-12 molar, comparable to skin prick test doses) are injected intradermally to desensitise patients with atopic diseases. It was first introduced by McEwen in the early 1970s. Mixed allergens (inhalants, foods or both) are given intradermally after mixing with the enzyme beta-glucuronidase, which is thought to enhance the desensitising eVect of the low dose allergen. Unlike conventional immunotherapy, EPD is an extremely safe technique, with a very low rate of anaphylaxis and other major adverse eVects. Injections are given two- to three-monthly instead of weekly. Thousands of injections have been given at the RLHH over the last thirty years with no systemic allergic reactions. It is not used for IgE-mediated food allergy. 348 allergy: evidence
4.3.3 Several clinical trials involving small numbers of subjects, conducted mostly in Italy over the last two decades, suggested safety and eVectiveness of EPD in hay fever and asthma and house dust mite allergy in children. The results in hay fever, however, were not confirmed by a larger clinical trial recently performed in the U.K. All the studies used the same mixture of inhaled allergens. Positive results using mixed food allergens have also been shown for childhood attention deficit disorder and childhood migraine. Despite the conflicting research evidence, many allergy patients continue to benefit from this treatment. It is hoped to demonstrate this with a program of prospective audit. 4.3.4 The clinic is fortunate to have a dietician who is expert in food allergy and intolerance, a rarity in such services. This enables patients to be treated who have adopted an unnecessarily restricted diet on the basis of spurious “food allergy tests” available on the high street, gradually broadening such diets, oVering authoritative advice, checking nutritional status and advising on supplements. It is also possible to eVectively manage conditions known to be variably improved by elimination dieting (including irritable bowel syndrome and rheumatoid arthritis) without compromising overall nutrition. 4.3.5 The Royal London Homeopathic Hospital hopes to expand its allergy services in the near future, with an increased emphasis on conventional as well as complementary management of allergy in order to provide a truly integrated service.
References (not printed)
5. The Evidence Base for Homeopathy in the Treatment and Management of Allergic Conditions
5.1 Thirteen randomised controlled trials (RCTs) published in the peer-reviewed literature have studied the eVect of homeopathy in allergic conditions. Clinical areas of investigation have been limited to seasonal allergic rhinitis (11 RCTs) and allergic asthma (two RCTs); 12 of them were placebo-controlled studies, the other was an equivalence trial. 5.2 Nine of these trials reported statistical analyses in favour of homeopathy, one found homeopathy to be inferior to placebo, and three observed no significant diVerences between patient groups. This overall positive conclusion from RCTs of homeopathy in allergy has support in the findings of six systematic reviews. Summary details of the nine RCTs with positive findings are listed below:
Authors and Date Main Results Reported in Publication 1 Aabel S, Laerum E, Dølvik S, Verum group had fewer and less serious symptoms during a certain Djupesland P (2000) period of the birch pollen season. Single-day P values ranged from 0.41 to 0.02, ie for some days the diVerences between verum and placebo were statistically significant. 2 Kim LS, Riedlinger JE, Significant positive changes from baseline to 4 weeks in the verum Baldwin CM, et al. (2005) group compared with the placebo group (P % 0.032 for rhino- conjunctivitis symptoms, P % 0.031 for activity impairment, P % 0.04 for reported health transition). 3 Reilly DT, Taylor MA (1985) Maximum clinical improvement in verum group in weeks 3 and 4, with maximum statistical significance in week 3 (P % 0.002). Substantial reduction in average consumption of antihistamine tablets in verum group compared with placebo at that time. 4 Reilly DT, Taylor MA, Mean change of VAS scores was –17.2 in verum group and –2.6 mm McSharry C, Aitchison T in placebo group (P % 0.02). Doctor-assessed scores showed similar (1986) reduction: –27.7 in verum group vs. –12.2 in placebo group (P % 0.05). Use of antihistamines lower in the verum group than in controls: total 11.2 cf. 19.7 tablets (P % 0.03). 5 Reilly D, Taylor MA, Beattie DiVerence in visual analogue score in favour of homeopathic NGM, et al. (1994) immunotherapy appeared within one week of starting treatment and persisted for up to 8 weeks (P % 0.003). Similar trends in respiratory function and bronchial reactivity tests. 6 Taylor MA, Reilly D, Homeopathy group had significant objective improvement in nasal Llewellyn-Jones RH, et al. airflow compared with placebo group (mean diVerence 19.8 l/min, (2000) 95 per cent CI 10.4 to 29.1 (P % 0.0001). allergy: evidence 349
Authors and Date Main Results Reported in Publication 7 Wiesenauer M, Ha¨ussler S, After observation time of 17 days, Galphimia was more eVective Gaus W (1983) than placebo (P % 0.01). Significant benefit in 34 of 41 (83 per cent) patients in verum group and in 21 of 45 (47 per cent) patients in placebo group; 3 weeks later in 30 of 37 (81 per cent) patients in verum group, in 20 of 35 (57 per cent) patients in placebo group. 8 Wiesenauer M, Gaus W, After 5 weeks of treatment, significant improvement of ocular Ha¨ussler S (1990) symptoms in 75 of 98 (77 per cent) patients in verum group and 52 of 103 (51 per cent) patients in placebo group (P ' 0.01). Improvement of nasal symptoms: 75 of 98 (77 per cent) patients in verum group and 48 of 103 (46 per cent) in placebo group (P ' 0.01). 9 Weiser M, Gegenheimer LH, Rhino-conjunctivitis Quality of Life Questionnaire score changed Klein P (1999) significantly in the course of treatment. VAS scores increased by 24 per cent in verum group and by 29 per cent. in controls. Global assessments of therapeutic eYcacy did not markedly diVer with respect to treatments or the rating person. Therapeutic non- inferiority of homeopathic vs. cromolyn sodium treatment was demonstrated.
5.3 Evidence is also available from non-randomised studies that homeopathy can be an eVective treatment in allergic conditions. An international, prospective, multi-centre study compared homeopathic treatment with conventional medical care in 456 patients with respiratory tract complaints including allergies. The primary outcome measure was the number of patients who were cured or had “major improvement” after 14 days of treatment; homeopathy was found to be at least as eVective as conventional treatment. A similar study carried out in Germany on 178 children with mostly allergic conditions reported significantly greater improvement after homeopathic than conventional treatment. Large-scale clinical observational studies in primary or secondary care in Europe have indicated a high proportion of follow-up patients with allergic complaints achieve good outcome from homeopathy. A report from a single clinic in Israel showed that homeopathic intervention led to modest economic savings and reductions in the use of medicines commonly used to treat allergies and their complications. Finally, high dilutions of two homeopathic medicines used for the treatment of allergic diseases (Lung histamine and Apis mellifica) were observed to have a significant eVect on human basophil degranulation in-vitro.
6. Is the Level of UK Research Adequate?
6.1 One of the arguments levelled against homeopathy is that its evidence base is weak. Problems with inappropriate study design and a lack of funds mean that there is strong but not unequivocal evidence to demonstrate the eVectiveness of homeopathy in clinical trials and much more research is needed. Homeopathic medicines do not attract pharmaceutical funding because they cannot be patented and there is consequently very little financial impetus. Non-commercial funding is extremely limited and good research proposals often fall by the wayside due to lack of resources, often relying on small charities with an interest in CAM. This situation needs to be addressed. 6.2 The Science & Technology Committee’s report on CAM in 2000 recommended the creation of a stronger research infrastructure for CAM and the DH allocated limited funds. None of these has been directed towards research into the homeopathic treatment of allergies. 6.3 The homeopathic approach has much to oVer but at present is limited to a smaller number of centres of excellence and individual practitioners. A great opportunity is being missed, particularly in view of the potential for savings on allopathic medicines with potentially serious side-eVects, such as corticosteroids.
7. Most Promising Areas of Research Into Preventing or Treating Allergy
7.1 Research is needed to confirm unequivocally whether specific homeopathic medicines are more eVective than placebo in the treatment of particular allergic conditions. It is also important to demonstrate convincingly with further pragmatic RCTs that homeopathy has clinical eVectiveness at least as good as conventional medical care. Since the mechanism of homeopathy’s in-vivo eVects remains to be elucidated, the study of allergy 350 allergy: evidence might aVord an opportunity for hypothesis-driven clinical research in this area: it has been proposed, for example, that homeopathy may help to regulate the Th1/Th2 lymphocyte imbalance that characterises allergic disorders.
References [not printed]
Memorandum by Dr Nigel J N Harper, Royal College of Anaesthetists
ANAPHYLACTIC REACTIONS OCCURING DURING ANAESTHESIA
Background Severe anaesthetic anaphylaxis is relatively uncommon. The incidence in the UK is not known accurately. The true incidence probably lies between 1:10,000 and 1:20,000 anaesthetics. Approximately 5 million anaesthetics are administered per annum in the UK for a wide variety of healthcare procedures including major surgery, childbirth and radiological imaging. Many individuals require repeated anaesthetics. Modern anaesthesia takes advantage of the specific attributes of several diVerent drugs, each administered for a specific purpose. Thus, a typical anaesthetic may comprise an induction drug, a maintenance drug, a potent analgesic, a muscle relaxant drug, an anti-emetic drug, reversal agents and synthetic intravenous fluids. In addition, the surgical procedure may necessitate the administration of antibiotics, radiological contrast agents and drugs which manipulate blood coagulation. All these drugs are administered in large doses, directly into the circulation and are capable of eliciting life-threatening anaphylaxis. The anaesthetic environment also includes latex and skin-antiseptics which may precipitate anaphylaxis during anaesthesia. The severity of anaesthetic anaphylaxis varies from the appearance of a rash, a moderate fall in blood pressure or the onset of treatable wheeze, to catastrophic hypotension, intractable bronchospasm, and cardiac arrest. The majority of these reactions are not fatal but there are approximately 5-10 deaths per annum. A considerably larger number of patients suVer with a range of permanent disabilities as a result of cerebral or cardiac hypoxia during the anaphylactic reaction, for example; poor memory, loss of balance, poor spatial awareness and permanent cardiac damage. The incidence of anaesthetic anaphylaxis appears to be increasing in line with the general increase in allergy. Previous exposure to the culprit anaesthetic drug is not a pre-requisite for anaesthetic anaphylaxis. Components of the molecular structure of many drugs given during anaesthesia are found in everyday life, for example in detergents, cosmetics or cough medicines. There is considerable cross-sensitivity between some anaesthetic drugs, especially muscle relaxant drugs. Following a relatively minor anaphylactic reaction, a second exposure may be life-threatening. Although the incidence of proven anaesthetic anaphylaxis is approximately only 1:10-20,000, many more patients require investigation because the clinical signs of anaesthetic anaphylaxis can be imitated by more common and benign events. For example, a significant fall in blood pressure may be the result of the interaction between the hypotensive eVect of the anaesthetic induction agent and long-term anti-hypertensive medication. Severe wheeze during anaesthesia may be the consequence of the mechanical eVects of tracheal intubation in a patient with irritable airways through asthma or heavy smoking. Most anaesthetists would see these events several times a year. The consequences of not investigating these phenomena may be serious. If these clinical events were, indeed, caused by allergic anaphylaxis, it is likely that future exposure to the anaesthetic drug, or an anaesthetic drug with a similar molecular structure, would endanger the patient’s life. A recent case in law emphasised the responsibility of the anaesthetist to refer this group of patients for expert investigation and diagnosis (Eastwood v Wright 2005).
Issues It is important that every case of suspected anaesthetic anaphylaxis is investigated by an expert team to: (a) Identify the causative agent so that it can be avoided in future. (b) Establish whether there is cross-sensitivity with other drugs. (c) Enable recommendations to be made concerning future anaesthesia on an individual patient basis. (d) Gather data concerning the patterns of allergy to individual drugs (a worthwhile report to the Medicines Control Agency can be made only when the causative agent has been established). allergy: evidence 351
(e) Establish whether certain factors predispose to anaesthetic anaphylaxis. (f) Identify optimal resuscitation management protocols. The expertise required for investigation anaesthetic anaphylaxis is required in a relatively small number of centres in the UK, but that expertise should be readily available to all patients. A number of immunologists, allergists and anaesthetists have expertise in the investigation of anaesthetic anaphylaxis. A high proportion of patients are required to travel long distances to their nearest specialist clinic, and waiting times are long. It is not unusual for a patient to have to travel 30 miles. Many cases of anaesthetic anaphylaxis are not referred for immediate investigation. Because of the complexities of modern anaesthesia it is necessary for patients to be seen by an anaesthetist with a special interest in anaphylaxis at the same time as seeing an immunologist or allergist. The author started the first combined anaesthesia and immunology clinic in the UK in Manchester in 1997 but expansion of bi- specialty clinics has been relatively slow and, currently, there are only 3 similar combined clinics. There are approximately six additional uni-specialty clinics in which patients are seen only by an immunologist or allergist. Nevertheless, progress has been made and The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has set up a working group to update its 2003 publication “Suspected Anaphylactic reactions Associated with Anaesthesia” in collaboration with the British Society of Allergy and Clinical Immunology and The Royal College of Anaesthetists. These bodies will shortly announce a national database for anaesthetic anaphylaxis, with on-line reporting. The Royal College of Anaesthetists runs an educational programme on anaesthetic anaphylaxis. Focused resources are needed to expand the number of bi-specialty clinics for the investigation of anaesthetic anaphylaxis.
Memorandum by the Latex Allergy Support Group
Background
1. The UK Latex Allergy Support Group (LASG) is a voluntary self-help organisation founded in 1996, with 300! members. The aims of the Group are to raise awareness of latex allergy, provide support for those aVected, and promote the safe and appropriate use of latex products and equipment. An advisory panel provides advice on medical and technological issues. 2. Allergy to natural rubber latex (NRL) was first described in 1979 and, as with other allergies related to an underlying atopic susceptibility, the past 15 years has seen its recognition as a health issue of increasing importance. Latex allergy is thought to aVect less than 1 per cent of the general population, although is commoner in certain groups who are regularly exposed to latex such as healthcare workers from widespread use of protective gloves, and most notably patients with spina bifida who have been exposed to NRL gloves and catheters. 3. Latex allergy is a reaction to the constituent proteins of NRL and is an example of an “immediate” Type I IgE-associated reaction, where symptoms generally appear within minutes of exposure. This is quite diVerent from allergy to chemicals used in the manufacture of rubber, which is a “delayed” Type IV hypersensitivity reaction taking some hours or days to manifest clinically. These two quite separate conditions are often confused by the public, and also by healthcare staV. Similar confusion often exists between “glove allergy” (which is usually a non-immunological irritant reaction) and latex allergy. 4. The clinical eVects of latex allergy are similar to those from peanut allergy in that most will have relatively mild local reactions, some will have more troublesome local and respiratory problems and a few will be at risk of potentially fatal anaphylactic reactions. It is not possible at present to predict which individuals may progress from mild reactions to anaphylaxis, or when a more severe reaction may occur. The greatest potential danger to an allergic individual comes from mucosal contact (surgical/medical/dental/obstetric gloves must be avoided) or from inhalation of latex (carried in the air by powder from glove or balloon). Patients presenting with anaphylactic reactions during surgery or with occupational asthma may be found on subsequent investigation to be latex allergic. 5. A diagnosis of latex allergy may have profound consequences for the patient from worry about the ubiquitous nature of NRL in the environment together with its potential for serious reaction. In addition, proper investigation of latex allergy is itself not without hazard. It is therefore important that patients with suspected latex allergy are referred to appropriately trained practitioners for accurate confirmation of the diagnosis (or equally important exclusion of this) and sound advice to be given, generally by an allergist, dermatologist or other clinician with a sub-speciality interest. 352 allergy: evidence
6. There is an overlap between NRL (a plant product) allergy and food (usually fresh fruit) allergy due to common / cross-reacting antigens. An allergic reaction to banana, kiwi or avocado (for example) may be the first clinical presentation of a previously undiagnosed latex allergy.
Quality of Life 7. Although there is an extensive published literature on latex allergy, there has been surprisingly little investigation into the impact of this condition on Health Related Quality of Life (HRQoL). Two surveys have been conducted in the UK. 8. The first study of 50 latex-allergic adults from Wales showed that some had experienced severe impairment of HRQoL as a result of their NRL allergy. Twenty five per cent required to change the nature of their work as a direct result of their allergy, this varying from transfer to a “latex-safer” environment within healthcare to the necessity for full career change. Thirty three per cent experienced diYculties when visiting doctor or dentist, such as having to explain necessary precautions or supplying their own latex-free gloves. 9. A further specific latex allergy HRQoL questionnaire survey of 153 adult LASG members showed that the highest scoring questions (ie having most impact on QoL) related to worry, mood and situations where latex avoidance could be problematic. Eighteen per cent were not working and 25 per cent had required to change jobs because of their latex allergy. 10. The same survey of 28 child LASG members showed that their highest scoring questions related to restriction of diet, play and sports, whereas for their parents worry about possible anaphylaxis or other severe physical reactions to latex had the most impact on QoL. Nine children had experienced diYculty at school because of their latex allergy. 11. The employment diYculties reported above contrast with studies from other countries where aVected individuals have been accommodated more easily, suggesting that with careful case management the eVects on employment can be mitigated. This perhaps reflects a lack of support from or understanding of latex allergy by UK employers or line managers.
Healthcare 12. Visits to healthcare settings are a major concern for patients with latex allergy because of the widespread presence of NRL (mainly gloves) together with frequently reported lack of healthcare staV knowledge or understanding of this condition. In the survey of 153 LASG adult members mentioned above, 80 per cent reported reactions to NRL-containing medical equipment, 60 per cent had experienced at least “some diYculty” in obtaining medical and/or dental care due to their latex allergy, and only 5 per cent were confident that they would be cared for in a latex-safe environment if they were to be admitted to hospital. 13. NRL is a hazardous substance for the purposes of the Control of Substances Hazardous to Health (COSHH) Regulations 2002, and healthcare organisations are expected to have in place robust policies, both to minimise the development of latex allergy in the workforce, and also to provide a latex-safe environment for allergic patients and staV. The UK Health and Safety Executive (HSE) have a web-site on latex allergy aimed at healthcare employers and employees which explains about latex allergy and how staV and patients may be protected http://www.hse.gov.uk/latex/index.htm 14. A National Patient Safety Agency (NPSA) Patient Safety Information Notice published the results of a survey of NHS organisations in England and Wales in 2005, from which three broad conclusions emerged http://www.npsa.nhs.uk/site/media/documents/1079–Patient%20safety%20information.pdf: (a) local organisations should ensure that they have a comprehensive working policy on the use and purchasing of latex products, supported by eYcient management arrangements (only 60 per cent had such a policy at the time of the survey—although this had risen to 85 per cent by 2006, continuing frequent reported incidents relating to communication and documentation suggest lack of education and/or enforcement). (b) products and packaging containing latex need to be easily identifiable—labelling and catalogue descriptions need to be unambiguous and clear (identification of latex content of medical equipment continues to be a problem and there is at present no European latex symbol for industry to adopt). (c) there is a need for greater choice of eVective and cost-eVective latex-free products and equipment— this remains a concern for many NHS purchasers and managers. allergy: evidence 353
15. Natural rubber latex has many positive attributes. Comfort, strength, biological protection and low cost have made latex gloves the standard choice for use within healthcare. Recognition of the problem with latex allergy has led manufacturers to reduce protein content and remove powder from medical gloves, although it is not yet possible to completely remove all NRL allergens. 16. Although reduction in NRL allergen content of medical gloves appears to have substantially reduced the number of healthcare staV acquiring latex allergy, the need remains to provide a safe environment within healthcare for those who are already allergic, a few of whom react to even tiny amounts of NRL in the environment. The recent NPSA survey and ongoing reports of adverse incidents show that there is still much to do to safeguard aVected individuals. 17. Non-latex (synthetic) gloves are now readily available for allergic staV and patients, and advances in technology are making these a viable alternative to latex gloves for all staV. Some healthcare establishments have already eVected such a change, although concern has been expressed in some quarters on issues relating to synthetic glove supply, degree of protection and potential for adverse reaction. 18. The Partnership Support Unit of the Scottish Executive Health Department released a document in 2005 giving guidance on glove choice for staV working in NHS Scotland. This advised that latex gloves may continue to be used when justified by risk assessment, but that unnecessary routine use of latex gloves should be identified and discouraged. 19. Otherwise within the UK, there has been no clear agreement or guidance on whether healthcare organisations should: (a) continue with routine use of latex gloves, except for those who are already sensitised or allergic, because their benefits outweigh the risk of causing allergic reactions; or (b) eliminate the risk of latex allergy by switching to synthetic gloves, considering the allergy risk to be greater than the risk of blood-borne virus infection or synthetic glove reaction This decision has been left up to each individual healthcare organisation to make. LASG feels that this is unsatisfactory, and that clearer advice on this issue should be provided at national level, and be subject to regular review in the light of ongoing experience and technological advances. 20. A further issue within healthcare relates to the use of NRL in the manufacture and presentation of medicines, eg rubber vial stoppers. Sourcing information of NRL content and latex-free alternatives (eg vaccines) can be problematic. An accurate and up-to-date national database would assist healthcare staV in safe choice of medication for patients with NRL allergy.
Balloons 21. Another significant concern for individuals with latex allergy is NRL balloons. In a recent LASG survey of 109 members (83 adults, 26 parents of children), 21 had required to use adrenaline following exposure to these. Sixty nine had experienced symptoms just from being in an enclosed area containing balloons and 81 said that their presence restricted access to public premises, from which 90 thought that balloons should be banned. Although scientific evidence is lacking on this issue, LASG has recently petitioned the European Commission to examine balloon safety, ways of improving this and to look at the question of labelling. 22. In 1998, The Medical Devices Agency (MDA) issued a Safety Notice informing healthcare organisations of the increased risk of allergy from powdered latex gloves, and these were subsequently removed from national contract two years later. As NRL balloons are also powdered, it does not make sense for healthcare organisations to permit these on their premises (eg for displays), having already removed powdered gloves for safety reasons. Some hospitals have taken steps to meet COSHH regulations and ban NRL balloons, although not many to our knowledge.
Other Issues 23. There is a dearth of available data, but anecdotal evidence suggests that latex gloves are widely used out- with the healthcare setting, for example in garages, restaurants and hairdressing salons. We do not know how allergenic these gloves are, but the need to minimise costs is likely to mean that many are cheap, powdered and highly allergenic. If this is the case, the gloves will be a risk both for those who wear them (from developing allergy) and also for their customers (eg from transfer of latex allergens to car interior or food). It is possible that widespread use of highly allergenic gloves in such occupations will produce a similar outbreak of overt allergy that has already been encountered in healthcare, and further study is required. 354 allergy: evidence
The Health and Safety Executive have recently produced a web-site aimed at hairdressers, entitled “Let’s cut out dermatitis” (70 per cent hairdressers suVer from this skin condition) http://www.hse.gov.uk/hairdressing/ index.htm. Non-latex gloves are specifically recommended by HSE, and LASG would welcome similar guidance to be issued to catering and automobile industries. 24. Similar concerns exist for latex glove use in care homes, where controls may be laxer than is the case within hospitals. In addition, there is some evidence that powdered latex gloves may commonly be used in schools for eg science, home economics and waste recycling, thus unnecessarily exposing substantial numbers of atopic children to NRL on a regular basis. Again, further study is required. 25. Although the Industrial Injuries Advisory Council recommended in 2003 that NRL be added to the list of prescribed causes of occupational rhinitis, that NRL be recognised as a cause of occupational asthma, and that anaphylaxis resulting from NRL allergy in healthcare workers be considered as a prescribed disease, there still appear to be diYculties for patients obtaining benefits or compensation for occupationally induced latex allergy.
Diagnosis and Information 26. Investigation and management of patients with suspected latex allergy can be time-consuming. Lack of trained personnel and competing demands on time in specialist clinics will inevitably compromise optimal management for some. A recent survey of 202 UK dermatology and allergy consultants who investigate for NRL allergy http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD%search&DB%pubmed showed substantial variation in diagnostic procedures, pointing to a need for robust guidance to assist more consistent practice across the country. Furthermore, patients referred with suspected latex allergy may subsequently be found to have rubber chemical allergy (see paragraph 3), and investigating physicians must have knowledge of and access to appropriate investigation for each condition. 27. The same survey showed that provision of basic information to help allergic patients cope with what can sometimes be a very daunting prospect is neither standard nor consistent. LASG has produced both basic http://www.hse.gov.uk/latex/pdf/patientinfosheet.pdf and comprehensive http://www.bad.org.uk/public/ leaflets/bad–patient–information–gateway–leaflets/latex/index.asp web-based patient information for hospital departments, although it is not clear how accessible this is for the general public. 28. Nearly 30 years on, there remains much confusion and misinformation about latex allergy. LASG sees the education of all healthcare staV, managers, employers and the general public as absolutely central to addressing this issue. We would welcome investment in key trained personnel in order to deliver and maintain the correct information, education and advice that is required throughout the country. 31 January 2007
Memorandum by the Patent Office
Executive Summary The Patent OYce is responsible for the administration of intellectual property rights. In addition, as part of the DTI Science and Innovation Group we are committed to playing an important role in supporting innovation in the UK. We are pleased therefore to support the House of Lord’s Select Committee on Science and Technology enquiry into allergic disease in the UK. Patenting is a key marker of innovative activity. In the following report we have endeavoured to provide information in the context of six of the questions outlined in the Call for Evidence:66 — What is allergy? — What is the diVerence between allergy and intolerance? — What is and what is not known about the origins and progression of allergic disease? — Treatment and management? — What is the evidence-base for pharmacological and non-pharmacological management strategies? — Is the level of UK research into allergy and allergic disease adequate?
66 http://www.parliament.uk/parliamentary—committees/lords—s—t—select/allergies.cfm allergy: evidence 355
— What are the most promising areas of research into preventing or treating allergy? A detailed analysis of patent information in a database containing patent records from all major industrialised countries was conducted. The report shows: — Chronological filing trends by country. — Trends in particular technologies, for example organic compounds, biotechnology and foodstuVs— globally, chronologically and by country. — The top 10 companies world-wide and top 10 UK organisations ranked by their patent activity. — An analysis of the top 50 inventors filing at the UK Patent OYce, their associated organisation and the relationships between those organisations. A significant body of world-wide patent filings on allergy derives from UK based pharmaceutical companies. The majority of this UK patent activity is on classical heterocyclic chemical pharmaceuticals. Whilst a number of UK organisations show innovative activity in the biotechnological aspects of the treatment of allergy, this area is less extensive than classical organic chemistry.
1. Introduction Reference to “patents” relates to both patent applications and granted patents unless otherwise indicated. For this study the European Patent OYce (EPO) database EPODOC was used which encompasses published patent documents derived from the majority of leading industrialised countries and patent organisations, for example the World Intellectual Property Organisation, EPO and the African Regional Industry Property Organisation (ARIPO). This report includes data in the period from 1996 up to and including 2005. However, it is pointed out that the apparent down-turn in 2005 may be due to the incompleteness of the database. Since patents are usually published eighteen months after filing, the data reflects the time when the information became available rather than when the research was carried out. The Patent OYce is currently trialling patent information analysis software, supplied by Thomson ScientificTM. The two pieces of software used to generate the data presented in this report are Thomson Data Analyser (TDA) and AurekaTM.
2. What is Allergy?
Question 1 Our study was based on a broad definition of allergy as “an inappropriate or exaggerated immunological response of the body to a substance”. The International Patent Classification system (IPC) now provides six “marks” specifically catering for allergy: allergens and pollen allergens, anti-allergic agents, antiasthmatics, antipsoriatics and ophthalmic antiallergics.
2.1 What is the difference between allergy and intolerance? We considered intolerance to relate to “a defect in the processing of substances within the body, particularly gastro-intestinally” which is distinguished from allergy because it does not necessarily require the significant involvement of the immune system. Food intolerances are often caused by enzymatic deficiencies. Patents relating to food intolerance enzymes and medicines that promote digestion also have specific marks in both international and domestic classification systems. Immunological intolerance is the physiological status quo relating to foreign material and characterised by a normal immune response. In this respect allergy is distinguished from immunological intolerance by the magnitude and often acute level of response. Both domestic and international classification systems provide marks for the identification of immunosuppressants and immunostimulants.
3. What is and What is not Known about the Origins and Progressions of Allergic Disease?
Question 2 There is a wealth of patent information on allergy. Nearly thirty thousand patents were identified. Over one third of these have been published in the last five years (Figure 1). In common with journal articles, individual patents are likely to outline and discuss contemporary theories surrounding a disease. The relative increase in patent filings in allergy this century reflects an overall trend in the patent activity in the area of biotechnology, 356 allergy: evidence pharmaceuticals and organic chemistry in general. This expansion of patent activity may to some extent reflect the increase in knowledge about underlying disease mechanisms as well as corporate intellectual property strategies.
Figure 1
Figure 1: Chronological trends in patent records relating to allergy
3000
2500
2000
1500
Number of Records 1000
500
0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year Figure 2: Chronological trends in patent records in biotechnology, pharmaceuticals and organic chemistry 250000
200000
150000
100000 Number of records
50000
0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year allergy: evidence 357
4. Treatment and Management
Question 6
There is a lag time between patent filings and time taken to get to market for therapeutic products. Nonetheless, a range of therapeutic strategies can be identified in a variety of patent classification areas: organic compounds, particularly nitrogen-containing heterocyclic compounds, recombinant genetic technology and antibody engineering (Figure 3).
Clearly the most prominent area of patent activity is in nitrogen-containing heterocyclic organic molecules. Within the biotechnology area, particularly notable is that the European Patent OYce classification scheme provides a specific term for antibodies against IgE indicating a significant level of patent activity in the area of limiting the allergic response by engineering antibodies (anti-idiotypic antibodies) against IgE. The other biotechnological area showing significant activity is in T-cell receptor-based inventions and the engineering of proteins making up that receptor or associated with it.
Strategies for diagnosis appear in genetic-based testing and immunoassays and these can also provide information about disease mechanisms. About 6 per cent of patents on allergy are concerned with genetic diagnostics and a similar number with immunoassays.
Figure 3: Distribution of patent documents by technology term
Number of Records 0 1000 2000 3000 4000 5000 6000 7000 8000 9000
Pharmaceuticals 8564
Therapeutic activity of compounds 4101
Heterocylic compounds 2331
Proteins/peptides/antibodies 1622
Microorganisms, cells, enzymes, genetic engineering 1552
Chemical diagnostics incl. immunoassays 1250
Testing, involving microorganisms, enzymes and nucleic acids (genetic testing) 697
Sugars, derivatives thereof incl. nucleic acids 595
Acyclic or carbocyclic compounds 435 Technology Terms Technology Preparation of compounds by fermentation, enzymes or microorganisms 431
Foods and foodstuffs 406
Biocides, pest repellants or attractants, or plant growth regulators 263
Diagnosis, surgery, analysing biological material 193
Animals, including transgenic animals 189
Chemical aspects of bandages, dressings methods of sterilisation etc. 184
Other 1658
5. Evidence-base for Pharmacological and Non-pharmacological Management Strategies
Clearly the abundance of patent information relates to pharmaceuticals and the majority of these are organic compounds. About 4 per cent of allergy-associated patents are found in the area of food modification. Direct genetic engineering based therapies comprise a small number, less than 30, of the overall therapeutic patents; notably half of these have published in the last five years. 358 allergy: evidence
6. Is the Level of UK Research into Allergy and Allergic Disease Adequate? UK-based companies GlaxoSmithKlineTM and PfizerTM rank first and third, respectively, in terms of the number of patents on allergy worldwide in the last 10 years (See Figure 4).
Figure 4: World-wide patent activities in allergy by organisation
Number of Records per Organization
GLAXOSMITHKLINE 245
MERCK SHARP & DOHME 233
PFIZER 226
SCHERING CORP 213
BAYER AG 201
BOEHRINGER INGELHEIM INT 180 Organisation
ONO PHARMACEUTICAL CO 148
AVENTIS PHARM PROD INC 139
NOVARTIS AG 133
ASTRAZENCA AB 104
0 50 100 150 200 250 300 Patents for the year range 2001:2005
6.1 Global patent activity in allergy Looking at the country distribution of the gross number of patent records in the last five years it is apparent that the UK ranks third behind America and Japan67 (see Figure 5). A comparison of the number of patent filings over the last five years measured against Gross Domestic Product in 2005 shows that the UK falls lower than Japan and the USA but is ahead of Germany (Table 1). Other European countries were not considered here because it is likely that organisations in these countries do not predominantly file directly in the country of origin but instead make first filings at the European Patent OYce.
Table 1
PATENT FILINGS/GDP 2005
Country Patent Filings/GDP 2005 (104 million USD)68 Japan 5.05 USA 4.32 United Kingdom 3.5 China 3.25 Germany 2.48
67 The data was extracted from priority patent filings—that is the country where the first patent filing was made as an indicator of filing in that country. In extracting this data European Patent designations were not counted 68 World Bank- World Development Indicators Database, 1 July 2006. allergy: evidence 359
Figure 5: Patent activity on allergy by country. US: America, JP: Japan, CN: China, DE: Germany, EP: European filings via the European Patent Office, RU: Russia, FR: France; DK: Denmark and SE: Sweden Number of Records per Country
US 5385
JP 2279
GB 782
CN 725
DE 691
EP 651 Country RU 318
FR 211
DK 171
SE 156
Other 1077 0 1000 2000 3000 4000 5000 6000 Year 2001:2005 published patents and patent applications
6.2 Technology activity across the globe A more detailed analysis of national activity by technology area is given in Figure 6. This plot indicates that the relative level of patent activity in the main technology areas for the UK is similar to US and Japan.
Figure 6: Technology activity by country. WO indicates global filings via the World Intellectual Property Organisation, US: America, JP: Japan, CN: China, DE: Germany, EP: European filings via the European Patent Office, RU: Russia, FR: France and DK: Denmark. Percentage of Technologies by Country 100%
80% Acyclic or carbocyclic compounds
Sugars, derivatives thereof incl. nucleic acids
Testing, involving microorganisms, enzymes and 60% nucleic acids (genetic testing) Chemical diagnostics incl. immunoassays
Microorganismsm, cells, enzymes, genetic engineering 40% Proteins/peptides/antibodies Heterocylic compounds
Pharmaceuticals 20%
0% US WO JP UK CN DE EP RU FR DK 360 allergy: evidence
6.3 UK patent activity on allergy An assessment of activity within the UK was conducted. The top 50 companies and top 50 inventors appearing on GB patent specifications were analysed (Annexes 1 to 3) (most of the inventors are based in the UK but where a company has an overseas location, ie USA, some of the inventors are based in that country).
Two universities, University of Southampton and the University of Oxford (ISIS Innovations) which include spin-oV organisations from them rank among the top 10 UK-based organisations filing in the field of allergy. Seventeen UK Universities/Medical Schools have filed at least one patent application on allergy. Of the top fifty organisations twenty have collaborated on patent filings.
Top 10 Organisations Filing UK Patent Applications in Allergy
No patents Patent Assignee 113 Smithkline Beecham CorpTM 61 AstraZeneca AbTM 33 Celltech Therapeutics LtdTM 29 Reckitt BenckiserTM 19 Peptide Therapeutics LtdTM 17 University of SouthamptonTM 12 Allergy Therapeutics LtdTM 12 Evolutec LtdTM 10 Circassia LtdTM 10 Isis InnovationTM
7. What are the Most Promising Areas of Research into Preventing or Treating Allergy?
Question 10)
A chronological analysis of technology terms (Figure 7) indicates that, whilst patent activity in pharmaceuticals and heterocyclic organic compounds continued to rise this century, activity in biotechnology appears to have slightly decreased. However, this could in part be due to changes in filing strategies by biotechnology organisations. Nevertheless biotechnology patent activity is higher than it was 10 years ago. Patenting in the area of non-cyclic organic therapeutic compounds appears to be relatively flat. allergy: evidence 361
Figure 7: Chronological trends of patents on allergy by technology cluster
Number of Records by Technology and Year
2000
1800 Pharmaceuticals 1600 Heterocylic compounds 1400
1200 Proteins/peptides/antibodies
1000 Microorganisms, cells, enzymes, genetic engineering 800 Chemical diagnostics incl. immunoassays 600 Acyclic or carbocyclic compounds 400
200 Testing, involving microorganisms, enzymes and nucleic acids (genetic testing) 0 Foods and foodstuffs 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
7.1 Top 50 Inventors filing in UK; their relationship with companies and field of activity To gain an insight into current patent activity two strategies were used: (i) analysis of 10 most cited patent applications; and (ii) analysis of the top fifty inventors filing patents in UK and to group these with their corresponding companies (Annexes 1 to 4). The 10 most cited patents all concern nitrogen-containing heterocyclic compounds. Analysis of the most recent patent filings from each company (see Annex 1) revealed a more diverse spread of activity within three main areas: (a) heterocyclic organic compounds; (b) biotechnology and (c) environmental allergen deactivation.
7.1.1 Nitrogen containing heterocyclic compounds The most abundant patent filings by GSKTM, MerckTM, PfizerTM, NovartisTM, AstraZenecaTM and CellTechTM all concerned nitrogen-containing heterocyclic compounds: — Knowles et al and Jones et al (GSK) phosphodiesterase inhibitors; — Maccoss et al (Merck)—tachykinin receptor antagonists; — Lethwaite et al (Pfizer)—bronchodilatory ß2agonists; — Warrellow et al (CellTech)—anti-inflammatory phosphodiesterase inhibitors; — Danahay et al (Novartis)—syngeristic anti-asthmatic compounds; and — Stocks et al and Baxter (AstraZeneca)—modulation of chemokines (interleukins and chemoattractants) with pyrazinyl phenylsulphonamides. 362 allergy: evidence
7.1.2 Biotechnology-based inventions — Ames et al (GSK)—recombinant peptides as therapeutic agents; Wheeler et al (also Allergy Therapeutics Ltd)—the surface modification of allergens; — GSK and Peptide Therapeutics collaborated on engineering protein vaccines (mimitopes) to neutralise IgE antibodies; —MoVat et al (ISIS)—recombinant proteins associated with IgE –mediated atopic disorders; and — Lamb et al (Lorantis)—modification of T cell interactions via cell signalling proteins (Notch) ligands.
7.1.3 Allergen deactivation The Reckitt BenckiserTM/University of Southampton collaboration produced patent applications on the deactivation of dust mite allergens with dispersable deactivants such as terpene hydrocarbon oils.
8. Conclusions There is an abundance of world-wide patent information relating to allergy. The main findings of this report are: 1. Patent trends in allergy mirror those of the biotechnology and pharmaceutical sectors. 2. GDP indicators suggest the level of patent activity in the UK is less than in the USA or Japan but at least as strong as Germany. 3. There is a substantial body of patent information emanating from the UK on classical organo- chemical pharmaceuticals relating to allergy. There are several UK institutions generating patent filings in biotechnology but the level of innovation is not as extensive as for classical organo-chemical pharmaceuticals. 4. UK private sector companies make a significant contribution to the patent landscape on allergy. Two UK university entities rank in the top 10 UK organisations in the field of allergy. 5. Patent databases provide the opportunity to perform a detailed analysis of the information and patent trends relating to particular molecules in the molecular pathways involved in the allergic response and also about particular companies and individuals involved in this area. allergy: evidence 363
Annex 1 Inventor collaboration, each group having at least 1 UK based inventor
AstraZeneca Merck & Merck Pfizer
Celltech
AstraZeneca / Sosei
ISIS
GlaxoSmithKline
GlaxoSmithKline Lorantis
GlaxoSmithKline
Novartis Peptide Therapeutics
Reckitt/Uni AstraZeneca Southampton
At least one inventor in each cluster is based in the UK. Where a company has an overseas location, ie USA, some of the inventors shown may reside in that country. The number of patents is indicated by the size of the dot. The bold lines indicate over 75 per cent collaboration. Dotted lines indicate less than 25 per cent collaboration. 364 allergy: evidence
Annex 2 UK-based companies or companies collaborating with UK-based companies
allergy: evidence 365
The number of patents is indicated by the size of the dot. Bold lines indicate over 75 per cent collaboration. Dotted lines indicate less than 25 per cent collaboration.
Annex 3
NUMBER OF PATENT RECORDS FOR TOP UK-BASED COMPANIES OR COMPANIES COLLABORATING WITH UK-BASED COMPANIES
No patents Patent Assignee 113 GlaxoSmithkline TM 61 Astrazeneca AbTM 33 Celltech Therapeutics LtdTM 29 Reckitt BenckiserTM 19 Peptide Therapeutics LtdTM 17 University of SouthamptonTM 12 Allergy Therapeutics LtdTM 12 Evolutec LtdTM 10 Circassia LtdTM 10 Isis InnovationTM 8 Phytotech LtdTM 7 Britannia Pharmaceuticals LtdTM 7 Corixa CorpTM 7 Helperby Therapeutics LtdTM 7 Imperial College 7 Lorantis LtdTM 7 PfizerTM 6 Acambis Research LtdTM 6 Cambridge Antibody TechologyTM 6 University of Manchester 6 Vernalis LtdTM 5 Imperial College Innovations LtdTM 4 Darwin Discovery LtdTM 4 Hewlett Healthcare LimitedTM 4 Human Genome Sciences IncTM 4 St George S Enterprises LtdTM 4 Wyeth CorpTM 3 Acaris Healthcare Solutions PlTM 3 Arakis LtdTM 3 Cambridge Bioclinical LimitedTM 3 Danbiosyst UkTM 3 Mars IncTM 3 Pilgrim Bed LimitedTM 3 SpesTM 3 University of Cranfield 3 University of LondonTM 3 Vectura LtdTM 2AVymax Tech NvTM 2 Beatson Inst For Cancer ResearchTM 2 Beth Israel Hospital 2 Biofocus Discovery LtdTM 2 BOC Group PlcTM 2 Boots Co PlcTM 2 Chiroscience LtdTM 2 Dzhejms Blehk Faundejshn LtdTM 2 E San LtdTM 2 Innovata Biomed LtdTM 2 Molecular Skincare LtdTM 2 National Research DevelopmentTM 2 Oratol LimitedTM 366 allergy: evidence
Annex 4
NUMBER OF PATENT RECORDS FOR TOP UK-BASED INVENTORS OR INVENTORS COLLABORATING WITH UK-BASED INVENTORS
No patents Patent Assignee 29 Mckechnie Malcolm Tom 28 Lane Charlotte 27 Lewthwaite Russell Andrew 24 Brown Alan D 24 Hughes John 23 Biggadike Keith 22 Bunnage Mark 21 Friede Martin 21 Glossop Paul 20 Warrellow Graham John 19 Mason Sean 18 Ward Peter 16 Alexander Rikki P 16 Clarke Jeremy G 16 Danahay Henry L 16 Hassan Ian F 16 Vinals Y De Bassols Carlota 15 Mantell Simon 15 Turnell William G 15 Van Mechelen Marcelle Paulette 14 Lewin Ian V 14 Maccoss Malcolm 14 Mills Sander G 14 Springthorpe Brian 14 Wheeler Alan Worland 13 Baxter Andrew 13 Bryans Justin 13 Chambers Jon 13 Stanworth Denis R 13 Stocks Michael 12 Cookson William 12 Jones Paul 12 Ladduwahetty Tamara 12 Paesen Guido Christiaan 12 Taylor Iain 11 Coates Anthony R M 11 Cornelius Gay 11 Dallman Margaret Jane 11 Edlin Chris 11 Horwell David C 11 MoVatt Miriam 11 Thompson Ian Andrew 11 Wheeler Alan 10 Ames Jr Robert S 10 Dorn Conrad 10 Foley James J 10 Hale JeVery 10 Knowles Richard Graham 10 Lamb Jonathan Robert 10 Monaghan Sandra Marina allergy: evidence 367
Memorandum by Research Councils UK
Key Points 1. Allergy is driven by immune mechanisms that range from acute (short-term) responses that can be potentially fatal to chronic (long-term) diseases such as asthma, eczema and rhino-conjunctivitis. The high prevalence and morbidity associated with these long-term illnesses can inflict a poor quality of life on suVerers and a high burden to the economy and the health service. 2. RCUK’s major contribution to research into allergy comes in the form of grant funding provided by the MRC and the Biotechnology and Biological Sciences Research Council (BBSRC). The MRC currently invests £5.14 million pa on research and training into allergy and the BBSRC £1.6 million pa. BBSRC also invests in allergy research via the Institute of Food Research. 3. In the UK, research into the underlying mechanisms of allergy and allergic disease is restricted to a few centres, but most of these groups are world-leaders in their field. Therefore, whilst research in this area needs to be encouraged, the existing researchers are of high international standing and the research funded is of excellent quality. 4. In 2004, the MRC carried out an analysis of its respiratory research portfolio. It concluded that its research spend on respiratory diseases, including asthma, was low in relation to morbidity. The MRC identified respiratory research as a strategically important priority. As a result of this, and through partnering relevant charities, the MRC has markedly increased its funding of research in this area from 6 awards (£0.5 million pa) to 15 awards (£2.0 million pa). Notwithstanding this, the UK Clinical Research Collaboration (UKCRC) subsequently identified that the research spend from all funding bodies on respiratory diseases, including asthma, is low in relation to morbidity. 5. MRC believes that working with partners will help tackle the broad challenges posed by allergic diseases. In addition to the collaborations with charities, the MRC has created partnerships with Universities in Edinburgh, London and Birmingham, to create Centres of research excellence into the allergic mechanisms of disease, inflammation and associated immunological processes.
Defining the Problem 6. The incidence of allergy in the UK is high and increasing, for example, more peanut hyper-sensitivity cases have been reported in the UK suggesting that peanut allergy is becoming more prevalent. Chronic allergic disease is now common, aVecting 20 per cent of households in the UK. EVective treatments for allergy are few and can be toxic. This is a driver for an increased research eVort which the RCUK has responded to through major investments in UK research. 7. From the patient’s perspective, allergy embraces conditions such as rapid sneezing, itching, rash, shortness of breath, and in its most extreme form, anaphylactic shock,which can be fatal if not treated quickly. From a research perspective, the term allergy is used to describe a hypersensitivity that results from altered or heightened reactivity of the immune system in response to external or “foreign” substances. These foreign substances are called allergens and examples include grass pollen, weed and tree pollens, house dust mites, fungal spores, animal proteins, certain foods (eg peanuts) and chemicals. 8. Allergens enter the body where they may come into contact with certain types of white blood cells known as mast cells and basophils. The allergen binds to a molecule on these cells known as IgE.69 Binding of IgE on these cells causes them to release histamine and other chemicals stored within the cell. These other chemicals, known as cytokines and chemokines, attract other types of white blood cells known as leukocytes to the area. The activation of these leukocytes, together with the initial activation of mast cells and basophils, is known as the inflammatory response and this produces marked changes in the muscles and blood vessels in the aVected area. It is this response that produces the characteristic symptoms associated with an allergic response.70 69 Allergens enter the body by inhalation, injection or through contact with food. They bind to specific IgE which itself is bound to high aYnity receptors (FcsR1) on the surface of mast cells and basophils. There also exists a low aYnity IgE receptor (FcER2) but its role is unknown. 70 Symptoms diVer depending upon the target tissue eg in asthma—contraction of smooth muscle causes bronchoconstriction and wheezing. In allergic rhinitis—nerve stimulation, vascular swelling and mucus secretion cause sneezing, rhinorrhoea and nasal obstruction. In anaphylaxis, systemic activation of mast cells and basophils causes massive release of mediators into the circulation leading to cardiovascular failure. 368 allergy: evidence
9. Coupled with this rapid response is the more, long-term, activation of a diVerent white blood cell known as the T helper 2 (Th2) cells. The activation of Th2 cells directs the production of more IgE molecules, produces more cytokines and chemokines and so attracts more leukocytes.71 This chronic response is important in orchestrating the immune system in allergic disease. Continued activation contributes to the persistent symptoms of allergy, for example, persistent airflow obstruction, that requires regular anti-inflammatory treatment often with corticosteroids. Chronic inflammatory conditions are of most concern as they can impose on suVerers a low quality of life, a high burden on the Health Service and a heavy economic impact due to working days lost. 10. There are also conditions caused by external substances that stimulate the immune system and Th2 cells without involving IgE-dependent cell activation. Examples include some forms of drug allergy, occupational asthma and some types of dermatitis. The mechanisms of Th2 cell activation in these diseases are unknown. Some forms of sensitisation, for example, contact dermatitis, involve a diVerent type of immune response known as the delayed-type hypersensitivity response. 11. Finally, there are also conditions caused by external factors such as foodstuVs which are not mediated by known immunological pathways and are often referred to as intolerances; these include disorders such as Irritable Bowel Syndrome and migraine. There are also conditions that are confusingly described as “allergic”, for example Attention Deficit Hyperactivity Disorder, chronic fatigue syndrome (CFS, ME) and multiple chemical sensitivity syndrome, where the evidence for an allergic basis is weak. 12. In summary, from a research point of view, an allergic response can be distinguished from intolerance as having its basis in an immunological process involving Th2 cell and (usually) IgE activation. Through complex pathways and mechanisms, this can lead to a specific type of chronic inflammatory response. Scientists supported by RCUK are working hard to discover the mechanisms by which the immune system is activated. This includes studies of Th2 cells, mast cells and the chemicals these cells release. Also, why the resulting inflammation can in some cases continue indefinitely leading to chronic and debilitating disease. The current state of allergy research might be broadly described as extensive knowledge about the underlying mechanisms of the complex pathways that lead to disease, but as yet too few eVective therapies. This is why a focus of MRC research strategy is currently to translate basic research knowledge into the development of new prophylactics and cures.
The BBSRC’s Contribution to Research into Allergy and Inflammation 13. The Biotechnology and Biological Sciences Research Council (BBSRC) funds work on allergy through studies on basic immunology and on food allergies at the Institute of Food Research. Six relevant projects funded at BBSRC-supported Institutes in 2005–06, cost £672,935 and in 2006–07, £741,859 was invested in three projects. The Institute of Food Research will be making a separate submission to the House of Lords Select Committee. 14. The BBSRC also currently funds University-based research totalling £193,828, as well as four studentships, for research training directly relevant to the study of allergy. In addition, both BBSRC and MRC support a significant amount of research on basic immunology which may be relevant to the mechanisms underlying allergic responses.
The ESRC’s Contribution to Research into Allergy and Inflammation 15. The Economic and Social Research Council (ESRC) is the UK’s leading research funding and training agency addressing economic and social concerns. We have an international reputation both for providing high-quality research on issues of importance to business, the public sector and government and for our commitment to training excellence, which produces world-class social scientists. 16. The ESRC’s funding of research into allergy is less central to our strategic objectives than some other Research Councils. However, we do fund research addressing an as yet largely un-explored area of the social implications and consequences of the rise in allergies, in particular focusing on food allergies and food intolerance. Very little is known about how lay and professional people define or explain food allergies and intolerance, how people live with them, or how those who cater for people’s food and health needs in a variety of institutional settings manage this growing challenge. 71 Th2 lymphocytes initiate isotype switching of B lymphocytes to IgE synthesis, augmenting recruitment of secondary leukocytes such as eosinophiis through the secretion of specific cytokines eg interleukins (IL) "4, "5, "13 and GM-CSF and chemokines eg the eotaxins and RANTES. allergy: evidence 369
17. In addition, the ESRC funds a wider range of research relevant to the area including research on the social contexts of risk and individual and social responses to risk, genomics and genomic identity, the environment and public understanding of science.
The MRC’s Contribution to Research into Allergy and Inflammation 18. The MRC funds research aimed at improving human health and has supported some of the most significant discoveries in medicine in the UK. The Council is committed to funding the highest quality proposals and has recently increased its investment in understanding inflammation especially in the respiratory system. Our current investment in this research is of the order of £ 5.1 million pa covering both immunology and inflammation research. The portfolio is summarised briefly at Annex 1. 19. The MRC’s research strategy in this area is further developed in Annex 2. The MRC believes that forming partnerships is an important approach to tackling the challenges posed by allergic diseases as evidenced through MRC partnerships with Universities to develop Centres of Research Excellence. The MRC is also partnering Asthma UK, the British Lung Foundation, the British Thoracic Society and the Morriston Davies Trustees in funding studentships that will build research capacity in this area.
Responses to Some House of Lords Committee Questions
What is allergy? What is the difference between allergy and intolerance? 20.This has been addressed in paragraphs 6 to 10.
What is and what is not known about the origins and progression of allergic disease? 21. This is covered in some detail in the Royal College of Physicians (RCP) Report “Allergy, the unmet need”. There is also an increasing literature on the origins of allergy. For diseases such as atopic dermatitis (eczema), food allergy and asthma, it would appear that the onset of the allergic state is in early childhood, possibly intra- uterine or during the first few months of life. Sensitisation to specific allergens has a strong genetic component but the rising trends in allergy worldwide is likely to be due to changes in the environment (Asher M I et al, Lancet 2006; 368: 733"43). 22. While exposure to new and/or previously uncommon allergens, such as peanuts, tropical fruits etc may in part explain some of the increased allergy seen in childhood, it does not explain it all (BioschoV SC, Curr Gastroenterol Rep 2006; 8: 374"82). Considerable interest has been generated in the role of diet (anti- oxidants, polyunsaturated fatty acids, unpasteurised milk and probiotic bacteria) and exposure to rural environments as protective against allergy possibly by programming the early life response to allergens (Perkin MR, Strachan DP, J Allergy Clin Immunol 2006; 117: 1,374–81). 23. Prospective studies from pre-conception to adulthood will be needed to address some of these issues. A number of human study cohorts already exist; for example, the MRC together with the Wellcome Trust, is a funder of the Avon Longitudinal Study of Parents and Children (ALSPAC) and the UK Biobank, both of which may be resources for such studies. MRC has contributed £4.5 million over five years toward the ALSPAC cohort and has committed £28 million for the recruitment phase of UK Biobank, planned to end in 2010. The MRC, in partnership with the University of Southampton, also funds the Southampton Women’s Survey. Their aim is to learn more about the dietary and lifestyle factors that influence the health of women and their children—including the eVect of these on allergies.
What gaps exist in establishing the overall disease burden for all types of allergy and what are the barriers to filling these gaps? 24. Three comprehensive enquiries into allergy and allergy services in the UK have been published.72 All of these have highlighted the lack of information about individual diseases and their burden, as well as commenting on service provision relating to allergy. It is clear that more information is required in this area so that health economic calculations can be undertaken. 25. It is not appropriate for MRC to comment on the provision of health services to those suVering from allergic disorders. 72 The Royal College of Physicians Report, 2003 “Allergy the unmet need”; House of Health Committee “The Provision of Allergy Services” Sixth Report of Session 2003–04; The NHS Enquiry, 2006 “A review of services for allergy—the epidemiology, demand for and provision of treatment and eVectiveness of clinical interventions”. 370 allergy: evidence
In addition to the impact on the Health Service what is the overall socio-economic impact of allergic disease? 26. The socio-economic impact of allergy maybe much greater than is commonly appreciated largely because allergy rarely occurs in a single organ and manifests through multiple organs. For example asthma and rhinitis occur together in over 80 per cent of patients with asthma (Demoly P and Bousquet J, Lancet 2006; 368: 711"3).The combined morbidity imposed by this multi-organ expression of allergy requires further research. A second element that needs to be taken into account is the eVect of allergic disease on patients’ lives. Recent studies have shown a large impact of diseases such as asthma, hay fever and atopic dermatitis on quality of life.
What is the effect of current treatments on the natural history of allergic disease? 27. It would appear that anti-inflammatory therapy for diseases such as asthma, rhinitis and atopic dermatitis do not aVect the natural history of these disorders. Specifically, corticosteroids have a marked suppressive eVect on the inflammation with control of symptoms, but as soon as the steroids are withdrawn the disease appears again sometimes more aggressively than before. The only therapy so far that has been shown to influence the natural history of allergic diseases is immunotherapy, a treatment not yet extensively used in the United Kingdom due to fears over side eVects, amongst other issues (Frew AJ, Clin Exp Allergy 2006; 36: 251"3). The only other factor that has been shown to influence the natural history of allergic disease is avoiding contact with the oVending antigen. This is only useful in certain instances, such as occupational asthma eg that experienced by small animal handlers. Interestingly, clinical trials have shown that allergen avoidance in children genetically at risk of asthma, either fails to influence the development of allergy or leads to even greater sensitisation (Simpson A & Custovic A, Curr Opin Allergy Clin Immunol 2004; 4: 45"51). This observation suggests that allergen reduction strategies in children may remove protective agents from the domestic setting as well as those leading to sensitisation. Thus, in summary, apart from limited allergen avoidance and immunotherapy, there are no current therapies that are known to influence the natural history of allergic disease or allergy in general.
What is the evidence base for pharmacological and non-pharmacological management strategies? 28. As stated above, most allergic diseases are managed by drugs that either treat the symptoms or suppress inflammation, but they do not influence the natural history of the disorder. There is evidence to suggest that allergen specific immunotherapy has beneficial eVects on the allergic immune and inflammatory responses in patients. This involves giving patients allergens or modified allergens by injection, or more recently, sub- lingually and has shown promise in allergic rhinoconjunctivitis and venom allergy. The benefits of this approach have not yet been tested in large scale clinical trials.
Is the level of UK research in allergy and allergic disease adequate? 29. It is worth noting firstly that although research in this field is limited to a few centres, the UK is a world leader in many specific aspects of research into the underlying mechanisms of allergy and allergic disease. 30.The UK Clinical Research Collaboration (UKCRC) analysis73 has identified that there is an imbalance in research funding for all respiratory diseases, including allergic diseases such as asthma, compared to the severity of disease as measured by the disability adjusted life years (DALYs). This did not surprise the MRC who had already issued a Highlight Notice (see Annex 2) and had started working closely with the British Thoracic Society, Asthma UK and British Lung Foundation to encourage the respiratory research community to bid for funding. The added value and agility of this partnership approach has been successful in stimulating new interest. The number of applications increased markedly between April 2005 and March 2006 and the number of awards rose from 6 awards (totalling £0.5m per annum) in 2004 to 15 awards (£2.0 million per annum) in 2006.
What are the most promising areas of research in preventing or treating allergy? 31. It is important to pursue several avenues of research to combat allergic disease. The MRC has funded several research programmes at the forefront of research into allergy, some of which are at Annex 2. Broadly speaking these can be broken down to: 1) genetic studies to identify the genes responsible for allergies, 2) cellular studies to find out more about how the cells of the immune system function in health and disease and 3) new treatment evaluations such as oral immunotherapy. Other avenues of future research include studies 73 (http://www.ukcrc.ora/PDF/UKCRC Health Research Analysis Report.pdf). allergy: evidence 371 into environmental aspects of allergy such as identifying new allergens, determining the eVect of reducing or increasing allergen exposure on allergy and the eVectiveness of pro-biotics as a treatment for allergic diseases. 32.Of special interest is the shaping of the early life immune response towards or away from allergy via pattern recognition receptors such as Toll-like receptors. Ligands that stimulate these receptors may have potential preventative and therapeutic potential. The production of recombinant allergens that generate protective immune responses without triggering an allergic reaction is another promising area of research. 33. The following questions posed by the House of Lords Science and Technology Committee have not been addressed as they lie outside of the remit of the Research Councils:
Government policies — How eVective have existing Government policy and advice been in addressing the rise in allergies? — How is current knowledge about the causes and management of allergic disease shared within Government? For example, — Do housing policy and regulations governing the indoor environment pay enough attention to allergy? — How eVectively are food policy and food labelling regulations responding to the rise in food allergies?
Patient and consumer issues — What impact do allergies have on the quality of life of those experiencing allergic disease and their families? — What can be done to better educate the public and to improve the quality of information that is available to patients and undiagnosed suVerers? — Are current regulatory arrangements, for example, those governing private clinics oVering diagnostic and therapeutic services and the sale of over the counter allergy tests, satisfactory?
Annex 1
SUMMARY OF MRC FUNDING IN ALLERGY AND IMMUNOLOGY
Allergy The MRC currently spends £5.14 million pa on allergy research. This is comprised of: £3.15 million for MRC grants to academic researchers in universities. £1.44 million for direct support in MRC Units and Institutes. £0.55 million for research training.
Immunology Research Underpinning Research into Allergy The MRC currently spends a further £15.3 million pa on research into basic immune function. This is comprised of: £5.7 million for MRC grants to academic researchers in universities. £7.9 million for direct support in MRC Units and Institutes. £1.7 million for research training.
Annex 2
MRC RESEARCH STRATEGY 1. The MRC recently highlighted the need for more research on respiratory disease—a manifestation of many allergic and inflammatory diseases by issuing a call for innovative research proposals. This call highlighted perceived barriers to progress in this area, such as the need for animal and/or human models of disease. Such models can be used to study disease mechanisms and pilot novel therapies. The call also highlighted the need 372 allergy: evidence to perform longitudinal studies to establish aetiology of disease. As a result, there has been a recent and significant increase in the MRC portfolio of funded research into allergy and related conditions of the respiratory system.
2. The commercial arm of MRC, MRC Technology (MRCT), is sponsoring major “showcase” events in 2007, on the subject of immunology, infection and inflammation. These will highlight the work of MRC-funded scientists to members of the pharmaceutical and biotech industries. It is hoped that this will increase partnerships between academia and industry and promote the translation of more basic research into therapy.
3. In November 2005, the MRC participated in a joint-funded workshop attended by other major stakeholders (the Wellcome Trust, Department of Health and the major charitable supporters of respiratory medicine: Asthma UK, the British Lung Foundation and British Thoracic Society) to encourage research in the field and identify any tractable barriers to progress. Several key individuals including the Director of the Wellcome Trust (Dr Mark Walport), the Department of Health’s Director of R&D (Professor Sally Davies); and the MRC’s Chief Executive (Professor Colin Blakemore) made keynote speeches on their current portfolios in the area. The 72 participants included senior scientists and a report has been published on the BTS website. Since this workshop, the MRC has also been very active in working with the respiratory charities to encourage high quality applications and increase the participation of the research community in new funding initiatives, such as the recent MRC call for funding of Experimental Medicine.
4. The MRC intends to work closely with the newly established UK Respiratory Research Strategy Committee. This Committee has been set up to promote the need for world class research into respiratory disease. It will produce updates for research strategy in consultation with its constituent groups and other outside bodies.
MRC Centres of Excellence
5. The MRC funds Centres of Excellence in partnership with UK Universities. This unique type of funding supports scientific strategy that links and reinforces existing work as well as fostering new lines of research. MRC funding for these Centres helps UK Universities develop and sustain research with a clear strategic direction in areas of importance for knowledge and health. Allergy research has benefited from three such centres.
6. The MRC-Asthma UK Centre in Allergic Mechanisms of Asthma was launched in September 2005. The Centre is funded by the MRC and Asthma UK with a grant of £0.9 million over three years and directed by Professor Tak Lee, King’s College London and Professor Tim Williams, Imperial College London. The three main aims of the Centre are: (1) to advance the understanding of allergic mechanisms in order to inform the development of new, eVective and targeted treatments; (2) provide high-quality, basic and clinical research training in allergy and asthma; and (3) provide quality public information on allergy and asthma in conjunction with stakeholders and partners.
7. The University of Edinburgh/MRC Centre for Inflammation Research (CIR) was established in 2000 with an MRC grant of £1.113 million over 5 years and is headed by Professor Chris Haslett. The Centre comprises 10 major groups and over 150 investigators to pursue co-ordinated interdisciplinary research into three key control points of inflammatory disease—the initiation, regulation and resolution of inflammation. The Centre brings together a critical mass of internationally outstanding researchers in inflammation harnessing the skills of both basic and clinical scientists. There is a keen interest in research training in the molecular cell biology of inflammation, which has been particularly successful in nurturing young clinical scientists, adding vital capacity to this research area.
8. The MRC also funds The University of Birmingham/MRC Centre for Immune Regulation directed by Professor Eric Jenkinson, contributing £1.5 million over five years. This Centre brings together 16 internationally regarded research groups, with complementary skills in studying the diVerent facets of immune responses and their regulation. It links basic research on immune regulation with the study of relapsing and remitting inflammatory conditions associated with immunological damage to joints or blood vessels. allergy: evidence 373
Other Examples of MRC-funded Research
9. The MRC has a well established commitment through intramural funding for research into allergy. Professor Sir Philip Cohen Director of the MRC Protein Phosphorylation Unit in Dundee, is a world expert on the intracellular mechanisms involved in immune- and inflammatory-cell activation. The steps involved in this activation may oVer new targets for drug interventions to prevent allergic disease. Professor Dan Cutler in the MRC Cell Biology Unit, London has been investigating the mechanisms by which white blood cells move from the blood vessels towards sites of inflammation and specific targets that can be attacked to prevent inflammation. Dr David Jackson from the MRC Human Immunology Unit, Oxford has been studying blood cell traYcking in inflammation and how these cells are controlled by the proteins released during inflammation. They have discovered that during inflammation, some white blood cells will actively bind inflammatory proteins and so cause their own activation. 10.The MRC also funds a number of novel, cutting edge programmes of research looking at inflammatory mechanisms in the lung. For example, MRC Professor Stephen Holgate and his team from the University of Southampton have been studying the cells lining the airways of the lungs and have shown that in asthmatics, these cells are more susceptible to injury. They have also shown that levels of a powerful immune system chemical, tumour necrosis factor (TNF) are much higher in the lungs of people with severe asthma compared to non-asthmatics. This raises the question as to whether drugs that TNF would be an eVective treatment for asthma and the Southampton team are carrying out these studies. 11. IgE-dependent mechanisms in allergic diseases such as asthma are clearly of fundamental importance in our understanding these diseases. The MRC is funding research at Kings College London led by Professors Brian Sutton and Christopher Corrigan to study the structures of these molecules and their receptors. Based upon these structural studies, they are designing small molecules to inhibit receptor interactions and control the allergic response. 6 October 2006
Memorandum by the Royal College of Physicians The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 20,000 Fellows and Members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. 1. In 2003 the Department of Health was advised by the Royal College of Physicians (supported by patients, their allergy organisations and other relevant professional organisations) in the enclosed report “Allergy: the unmet need”—that: — The UK is exposed to an epidemic of allergic illness; one third of the population is directly aVected; the growth in severe allergy, allergy which expresses itself in novel forms and multiple allergy are especially concerning. — The NHS is not responding to the increased need for services (at any level of care); and people with unmet needs are being diverted into inappropriate care pathways. — Whereas a comprehensive service development plan is ultimately required, the first and essential step is to get properly qualified clinical staV into the front line of service provision. This requires a strategic investment in training—initially and primarily in the training of specialist allergy doctors who can take leadership roles in the development of the specialty. 2. In 2004 these findings and advice were endorsed by the House of Commons Health Committee. 3. The DH responses (DH Command paper January 2005, and subsequent Review, July 2006) were initially disappointing as they did not recognise the scale of need. 4. The DH has now conceded the need for improvement, and that there is enough known to move forward; but have allocated responsibility to PCTs and SHAs. However, it is far from clear if these bodies have access to experts in allergy. 5. The College, at a round table chaired by the then President, Dame Carol Black, reached a consensus on referral pathways and models of care with potential providers of allergy care (specialists in allergy, physicians in other specialties, and other colleges especially paediatrics, RCPCH, and primary care, RCGP). 374 allergy: evidence
6. Underpinning this concensus was the training of more specialists in allergy, who could provide specialist care and support developments and improved education in primary care, and, working in partnership, across the NHS. An absolute requirement is the creation of more new training posts in allergy (beyond the current eight available nationally). 7. Research and developments in clinical care are essential to improve patient care for allergy suVerers in the UK. Research needs to have a particularly clinical focus. However, without a more robust specialist clinical service, with well studied patients and more doctors who specialise in allergy this will not happen. At present there are few allergy specialists (26.5 whole time equivalents in adult and paediatric allergy in the UK) and many of these are supported by academic funding, so these posts may not continue beyond the tenure of the current post holders.
Letter from the Royal Pharmaceutical Society of Great Britain
The role of community pharmacists in allergic conditions Community pharmacists provide support to people with allergic conditions in a variety of ways: — By supplying and advising on appropriate over-the-counter medicines. The choice of anti-allergy products is vast and potentially bewildering for allergy suVerers: the pharmacist can help them recognise symptoms, identify allergy triggers and select appropriate products. By developing an ongoing relationship with these patients, pharmacists can take a proactive approach by, for instance, encouraging patients to begin hay fever treatments before symptoms start. Pharmacists can also warn patients about side eVects and interactions with other medicines eg for high blood pressure.74, 75 — By providing advice on how to take prescribed medicines for allergic conditions. — By providing specialist medicines management services for allergic conditions. — By prescribing and supplying prescription-only medicines for allergic conditions (this would apply to pharmacists who have successfully completed accredited training courses to become supplementary or independent prescribers). I have attached at Appendix 1 a paper prepared especially for this response by Shailen Rao on the role of pharmacists in the management of allergic conditions. It reflects the personal perspective of a pharmacist who has been involved in medicines management and pharmacy development in the NHS. Some pharmacies sell diagnostic tests for allergies. However, these test kits may also be stocked in non- pharmacy areas of larger retailers, eg with a range of other health-related items, and in those circumstances the sale will not be supported by the advice of a pharmacist. The RPSGB has recently conducted detailed research on the contribution of pharmacists to managing three long-term conditions—asthma, diabetes and coronary heart disease.76 Key findings of the research included the following: 1. The average community pharmacy serves around 450 patients with asthma (based on national prevalence figures).77 2. Ten intervention trials of community-pharmacy based asthma services were identified and reviewed. 3. Seven of the 10 trials showed positive eVects on asthma control. 4. The most eVective use of community pharmacy resources will be to focus on those whose asthma is less well controlled, or could become uncontrolled. 5. Several models of community pharmacy based asthma care are oVered in the UK, usually on a pilot basis. 6. Community pharmacists have identified asthma as an area in which they would like to oVer a more clinical service. 7. Some other countries have been suYciently convinced by the evidence of pharmacists’ eVectiveness to fund a pharmacy based asthma service.78 74 Bokma A (2006). Clearing the air for allergy suVerers—pharmacists ease patient confusion. Pharmacy Practice Canada 22(6); A13–A15. 75 The role of pharmacists in advising patients with allergies was recognised in the Department of Health’s 2006 review of allergy services— Pharmacists need to advise public about allergies. Pharmaceutical Journal 277; 124, 29 July 2006. 76 http://www.rpsgb.org.uk/pdfs/ltcondintegcommphsumm.pdf 77 http://www.rpsgb.org.uk/pdfs/ltcondintegcommphreptl.pdf 78 http://www.rpsgb.org.uk/pdfs/ltcondintegcommphrept3.pdf allergy: evidence 375
What formal training do pharmacists receive in alergy at pre- and post-graduate level? Registration as a pharmacist requires successful completion of a four-year MPharm degree, a further year of pre-registration training within a pharmacy workplace, followed by a registration examination. At undergraduate level, the pathological and immunological basis of allergy is covered, as is treatment for symptoms with prescribed and over-the-counter (OTC) medicines. Details of the relevant parts of the pre- registration programme and registration examination syllabus are attached at Appendix 2. At postgraduate level, we are not aware of a compendium of courses, so to identify higher education courses of relevance to allergy would require examining the prospectuses of individual higher education providers. The Centres for Pharmacy Postgraduate Education in England,79 Scotland80 and Wales81 have programmes that include allergy in several forms—as a discrete topic such as asthma and also as part of a wider topic—eg eczema in skin disease. CPPE (England) does not have any specific courses) on allergy, but it is building one this year with Allergy UK (no further details are available at this stage). It has an open learning programme on respiratory disease which covers asthma (about 1,000 are sent out each year) and one on skin disorders which looks at atopic eczema (about 1,500 per year of these have been sent out). It hosts an allergy workshop but very few of these have been run in the last few years.
Do pharmacists feel they receive enough information and support in order to competently advise the general public about allergic diseases? The RPSGB has produced a range of resources which pharmacists would find helpful advising the public about allergic diseases, eg — The self-care challenge—a strategy for pharmacists in England (2006).82 — Practice guidance on the care of people with asthma and COPD.83 The RPSGB provides a Technical Information Service staVed by experienced information specialists. The Society also provides a Legal and Ethical Advisory Service. Questions from pharmacists about allergic disease would normally be dealt with by the technical information service. The Society does not have statistics on the volume of enquiries on specific medical conditions such as allergy. Two departments of the Society, the Technical Information Service and the Research and Development Division, undertook literature searches for this response on the topic of pharmacists and allergy. Additional references which do not appear in the footnotes are attached at Appendix 3. The Pharmaceutical Press (an imprint of RPS Publishing, which is owned by the RPSGB) produces a wide range of textbooks for pharmacists and pharmacy students. Those of relevance to allergic conditions include Asthma in Focus (2006) and Non-Prescription Medicines (2006).84 We have not found any evidence that pharmacists feel they have insuYcient knowledge or support to competently advise the public about allergic disease. Allergies are among the most common conditions for which the public visit pharmacies and seek the advice of pharmacists, so pharmacists are likely to be familiar with allergic conditions and their management.
The Department of Health told this Committee that a new regulatory framework for pharmacists should be introduced this year. What will this involve? Does the Royal Society welcome this? What benefit will this have to the general public? The RPSGB has welcomed the Pharmacists and Pharmacy Technicians Order 2007, which was made on 7 February 2007. The new legislation will overhaul and modernise pharmacist and pharmacy technician regulation and will update, strengthen and clarify the RPSGB’s powers to protect, promote and maintain the health and safety of the public. The main provisions of the Order are: — Improved capacity to address fitness to practise issues and health matters. — Reform of the Society’s registration process.
79 http://www.cppe.manchester.ac.uk 80 http://www.nes.scot.nhs.uk/documents/publications/classa/Pharmacy–newsletter–2004–spring.pdf 81 http://www.cfac.uk/phrmy/WCPPE/syllabus.html 82 http://www.rpsgb.org/pdfs/selfcarechallenge.pdf 83 http://www.rpsgb.org/pdfs/asthmaguid.pdf 84 http://www.pharmpress.com/shop/collection–display.asp?mscssid%D091667VFIML8MUDWULF7AUA1DH3EH27&SiteLanguage% ENG&CurrencyID%7&PageType%cat&CollectionID%%4000000000172 376 allergy: evidence
— Updated provisions for education, training and continuing professional development (CPD). — Statutory registration of pharmacy technicians in England and Wales. The Order has been developed as a result of close co-operation between the Department of Health, the Royal Pharmaceutical Society of Great Britain and the UK devolved administration health departments. There are separate arrangements for the regulation of pharmacy in Northern Ireland.
Which treatments are most commonly bought in pharmacies for the treatment of allergic conditions? The Proprietary Association of Great Britain provides total sales figures (supplied by Information Resources Inc) for OTC medicines but the figures do not distinguish sales from sales in other outlets. Most of the categories used in the figures do not distinguish allergic from non-allergic conditions. However, they show that £79.1 million was spent on OTC hay fever remedies in 2005, a rise of 4.5 per cent compared to the previous year.85 The total OTC sales of hay fever remedies have doubled in the past six years. Hay fever remedies are sold for a range of allergic conditions and sales take place all year round.86 Another information provider, IMS HealthC, has supplied figures for this inquiry. For the year March 2006 to February 2007, pharmacy sales of OTC medicines used for allergic conditions totalled £47,574,208, a rise of 5.45 per cent in the total value of sales compared to the previous year. The sub-totals for the four categories of medicines making up that total are: — Asthma remedies (£490,122). — Respiratory and general anti-allergics (£25,634,167). — Skin irritation including topical antihistamines (£14,756,075). — Eye anti-allergies and anti-inflammatories (£6,693,845). The figures are for pharmacy independents and multiples but do not include mass market channels such as Boots, Superdrug and the supermarkets.87
What diagnostic tests are available over the counter for allergies and does the Royal Society recommend these? The RPSGB’s Technical Information Services published guidance on diagnostic testing in community pharmacy in 2006.88 It includes information on providers of allergy and food intolerance testing. The Society does not make recommendations as such regarding particular tests or suppliers of tests. Additional information on diagnostic tests for allergies is attached at Appendix 4. The RPSGB also produces general guidance on diagnostic testing and health screening in its Code of Ethics (Service Specification 14).89
APPENDIX 1
The Role of Pharmacists in the Management of Allergic Conditions
Background Community Pharmacists currently provide a wide range of services and support to patients with allergic conditions and associated conditions eg allergic asthma. The main role at present is the over the counter (OTC) diagnosis and supply of medicines to manage mild allergic respiratory and skin conditions eg hay fever and allergic contact dermatitis. Recent changes in NHS policy and a drive to extend the rota of health care professionals eg practice based commissioning, extended prescribing and the new pharmacy contract provide an opportunity to further enhance the role of pharmacists in the management of allergic conditions. 85 http://www.pagb.co.uk/pagb/downloads/marketinformation/FINAL%201R1%202005%20OTC%20Data%20for%2 0PAGB.pdf 86 Personal communication, IRI, 17 April 2007. IRI compiles a comprehensive database of OTC medicine sales from all the major pharmacy multiples and supermarkets. It provides “top-line” data to PAGB but more detailed information is available at a charge, eg on the sales of particular OTC medicines and where they were brought. 87 IMS HealthC, 23 April 2007. 88 http://www.rpsgb.org/pdfsrpsepicdiagtest.pdf 89 http://www.rpsgb.org/pdfs/coe060524.pdf allergy: evidence 377
The Current Service Pharmacists are already recognised by the public as a key resource in the treatment of mild allergic conditions. They are regularly consulted by patients who present with symptoms of allergy. Many of these patients prefer to see a pharmacist rather than to take time oV work to visit a GP. In the first instance, many patients will not know that the condition is allergic in nature. Pharmacists are well skilled in using over the counter questioning techniques to establish potential allergic conditions and also have at their disposal a wide and growing range of first-line treatments, without the need for a prescription. These include oral antihistamine therapy, topical skin preparations eg hydrocortisone cream and cromoglycate eye drops. Pharmacists also provide information and education on prevention and minimisation of symptoms. Many of these patients will continue with over the counter treatment and others will see their GP for future treatments. Pharmacists also provide a very important role in referring patients suspected as having more serious conditions to their GP eg asthma and eczema. By providing this comprehensive and patient centred OTC service, a huge number of GP consultations are probably avoided each day across the country. In addition, OTC purchasing by patients rather than seeking a GP prescription reduces the burden on the NHS drugs bill. In some areas, allergic conditions are included as part of Minor ailments schemes commissioned locally by PCTs. In these schemes, patients with symptoms of minor illness are directed to pharmacies by GP practice reception staV. The pharmacist is enabled to triage the patients and either provide treatment or refer to the GP. Many patients with allergic conditions will be on regular medication eg antihistamines. However, in many cases, compliance is likely to be poor, often caused by a lack of knowledge about the condition or the medication. Pharmacists could be well placed to utilise medicines use reviews (MURs), which are part of the national pharmacy contract, to improve adherence to medication. It is probably unlikely that this is being explored as a specific opportunity as yet. In addition to community pharmacy, prescribing advisers in GP practices have been involved in the management of allergic conditions. This includes advice to GPs on drug choice and running audits within practices to review use eg antihistamines. In recent times, a number of prescribed antihistamines have come of patent and therefore reduced in price. Pharmacist involvement at practice level has helped GPs to endure that treatment remains cost-eVective. Hospital pharmacists play a key role in identifying allergies, specifically drug allergies; recommending safer alternatives and ensuring appropriate use of medicines during hospital admissions. Pharmacist led NHS medicines information services also provide information and advise on identifying and managing patient drug allergies; for healthcare professionals and the general public.
A Potential Future Pharmacy Service in Allergy Whilst pharmacists already provide a valuable role, it would be possible to enhance the value they add by better integration of within local NHS service delivery. A number of recent initiatives and policy documents would empower such a role: — The pharmacy contract. — Practice based commissioning (PBC) — Extended prescribing rights. — Practitioners with specialist interests (PwSIs). — Choosing “Health Through Pharmacy”. Pharmacists could become a first port of call and specialist medicines support service, recognised by patients and health care professionals across the whole health economy. In order for this to happen, a local service specification would need to be drawn up. A brief description of an example specification is given below: 1. Patients could continue to present over the counter (as they do now). 2. Pharmacists would run regular health promotion campaigns to raise awareness of allergies and the presence of pharmacy as a resource. This could fulfil part of the requirement to run health promotion campaigns under the pharmacy contract. 3. GPs would refer patients with allergies to be managed by the community pharmacist. This could be done either by use of a patient group direction (PGD) or where possible by utilising independent/ supplementary prescribing. The pharmacist could then continue the management of the patient ensuring that the patient is complying and altering medication as required. 378 allergy: evidence
4. Patients already being treated by their GPs could be referred to the pharmacist for support with prescribed medication. The pharimacist could utilise MURs to ensure that the patient is gaining benefit whilst also minimising the potential for wastage caused by unused or unwanted medication. 5. The service could be broadened to include patients with allergic asthma. Pharmacists would be well placed to provide support on the use of inhaled medications. 6. In the future, it may be possible to commission an allergy testing service through pharmacy. Some pharmacies already provide a testing service but at present these tests are not always of a standard recognised by other health care professionals. Potential Benefits of the service: 1. Improved access to services for patients. 2. Improved patient knowledge and understanding of the condition and treatments options. 3. Cost-eVective utilisation of pharmacists—some of these resources eg MURs, health promotion campaigns are already funded but may be under utilised. 4. Workforce development of pharmacists—improved knowledge via training on PGD and extended prescribing. 5. Improved working relationships between GPs and pharmacists. 6. Reduced workload for GPs. 7. Improved eVectiveness of prescribed medication and reduced wastage.
Conclusion Pharmacists in all sectors of the health community are a valuable source of identifying and managing allergies, specifically drug related ones. Community pharmacists currently provide an extensive service in the management of allergic conditions. In the main, this is an OTC service dependent on the patient self-presenting in the pharmacy. Some patients will either suVer in silence with conditions that could readily be treated, whilst others will present at GP practices and possibly even in hospital. With the changing NHS agenda, there is now a move to utilise a wider range of healthcare professionals, especially in primary care settings. These initiatives provide the means for engaging primary care pharmacists to improve the management of allergic conditions. In order, for the potential to be realised, NHS organisations should be encouraged to develop care pathways for allergic conditions and explore how pharmacy services could be integrated within them. Although additional funding may be required, it is possible that much of the existing resource eg MURs and GP practice prescribing budgets could be better utilised making such a service cost-eVective at the same time as being high quality.
APPENDIX 2
Pre-registration Education and Training Requirements for Pharmacists of Relevance to Allergies Dr Nicola Tyers, Preregistration Manager, RPSGB
1. Pre-registration Performance Standards (Learning Outcomes of the Pre-registration Year) Although there is not an explicit requirement for MPharm students to specifically cover allergy, this topic will definitely be covered within the area of Pharmacy Practice and specifically in Responding to Symptoms, and Clinical Pharmacy training. Also, in the pre-registration Performance Standards there is not an explicit requirement for trainees to cover allergy, other than C2.10, which deals with emergency first aid. It is not realistic to provide a list of all topics that trainees should cover as part of their core Performance Standards, but rather a list of outcomes in dealing with diVerential diagnosis and recommendations of treatment. Trainees are not specifically trained in diagnosis. The following Performance Standards do amount to assessing situations and providing solutions. Trainees must show that they: allergy: evidence 379
A3.1 Recognise and define actual or potential problems.* * Problems include diYculties, minor and serious, needing resolution. A3.2 Identify workable options to resolve the problem. A3.3 Select the best solution, based on sound analysis* and appropriate evidence. * Sound analysis will include: — Exploring the strengths and weaknesses of options. — Considering barriers to resolving the problem. — Discussion with others. A3.4 Suggest and, if appropriate, implement solutions to problems. A3.5 Evaluate the outcome of the solution after implementation, and if necessary redefine the problem (see A3.1). B1.11 Provide information and advice appropriate to the needs of the recipient(s)*. * Recipients must include individuals, groups and those with particular needs, eg people with diabetes, asthma etc. Unit C—Medicines and health standards encompass aspects of performance and behaviour that are specific to pharmacy practice and cover responding to symptoms. I would suggest that an integral part of dealing with responding to symptoms would be the diagnosis and treatment of allergy. In this Unit, trainees must demonstrate their ability to provide an eVective pharmaceutical service. Development of the following characteristics will underpin their future role as a provider of pharmaceutical care: — identifying health needs and understanding the opportunities for health promotion as well as treatment and care; — working with patients and carers, to manage their medicines and ensure that they can play an active part in the decisions and choices aVecting their treatment or care; — understanding and making the most of the whole health and social care system—for the benefit of patients. For this unit to be achieved, trainees must have experience or awareness of the following: — supply of medicines from both community and hospital; — provision of advice about medicines and health; — use of patient medication records and histories. Performance Standard C2—Provide additional clinical and pharmaceutical services Trainees must demonstrate the application of their clinical and pharmaceutical knowledge. Trainees must show that this knowledge is up-to-date. It must be used eVectively in the following areas: — the management of prescribed medicines, long term conditions and common ailments; — the promotion and support of healthy lifestyles; — the provision of advice and support to patients and other healthcare professionals. Competence in this element will underpin trainee’s ability to manage medicines and provide pharmaceutical care in the future. Trainees must show that they: C2.1 Provide considered and correct answers to queries, founded on research-based evidence*. * Evidence sources will include clinical textbooks, journals and pharmaceutical company information (whether paper-based or electronic). C2.2 Pro-actively* assist patients** to obtain maximum benefit from their treatment. * This will include identifying opportunities to assist, providing information, positive reinforcement, reassurance, testing understanding and encouraging recipient to ask questions. ** Directly or via their representatives. C2.6 Use medication histories correctly*. * Access existing information, record new information and apply the information. 380 allergy: evidence
C2.7 Recognise possible adverse drug reactions, evaluate risks and take action* accordingly. * This may include advising and informing patient or representative, discussion with colleagues and reporting to CSM. C2.8 Provide appropriate information and advice on the management of minor and common ailments*. * Information and advice must incorporate both appropriate self-medication and appropriate non- drug actions.
C2.9 EVectively use opportunities* to promote and support healthy lifestyles and prevent disease. * With individual patients and at formal events such as presentations to patient or public groups. The above includes Performance Standards that could be used to test diVerential diagnosis. Items highlighted in bold should cover allergy. It is important to remember that allergy could also include an allergic response from a medication.
2. Registration Examination Syllabus Items highlighted in bold below should cover allergy, although not specifically mentioned.
SYLLABUS SECTION 2—CLINICAL AND PHARMACEUTICAL PRACTICE
Part I—Clinical Practice
(a) Evidence-based practice You must be able to demonstrate an understanding of: — The principles of obtaining and applying evidence to inform and enhance practice. (b) Action and uses of drugs You must be able to demonstrate an understanding of: — The mechanism of action, administration, absorption, distribution, metabolism and excretion of commonly prescribed and purchased licensed medicines. — The principle uses of these medicines. — Correct dosages and dose adjustments for patients with particular needs because of their age or condition. (c) Non prescription remedies You must be able to demonstrate an understanding of: — The actions and licensed uses of medicinal products available without prescription that are commonly used to treat minor ailments. (d) DiVerentiating minor illness You must be able to identify and to demonstrate an understanding from more serious disease of: — The symptoms of conditions that require referral to a medical or other healthcare practitioner. — Conditions not requiring referral and how they may appropriately be treated by non-precription medicines, by short- term action that does not involve medication or by lifestyle change. (e) Adverse eVects of medicines You must be able to demonstrate an understanding of: (see also section 3, item e) — the recognised adverse eVects of commonly prescribed and purchased medicines. (f) Contra-indications You must be able to demonstrate an understanding of: — the circumstances in which commonly prescribed and purchased licensed medicines are contra-indicated. (g) Drug interactions You must be able to demonstrate an understanding of: — the principle interactions that can occur between medicines, prescribed and purchased, and between these medicines and foods or other substances. allergy: evidence 381
(h) Counselling requirements You must be able to identify and demonstrate an understanding of:
— circumstances or situations in which patients or other clients require information.
— the nature of that information and the most appropriate way to provide it to the individual.
(i) Optimising patients’ drug therapy Understanding of:
— The purpose and principles of medicines management and pharmaceutical care.
(j) Interpretation of test results You must know, demonstrate an understanding of and be able to interpret:
— The normal ranges for blood pressure and key blood components.
— The normal ranges for therapeutic blood levels of drugs with a narrow therapeutic index.
— The normal ranges for key parameters of bodily function.
— The implications of figures outside these ranges.
(k) Health promotion and disease You must be able to demonstrate an understanding of: prevention — The concepts of health promotion and health education.
— Recommendations for key health parameters.
— The basis for health improvement programmes.
— The social, environmental, lifestyle and dietary factors that influence health.
— How awareness of the stages of behavioural change can help the pharmacist to make interventions appropriate to the individual.
— Actions the pharmacist and pharmacy support staV can take to promote health and prevent disease.
Asthma is only mentioned as an example in the standards. We deliberately do not have a definitive list of topics as things are always changing. Trainees will be exposed to learning about allergy in practice.
The overarching information about Performance Standard C2 does state that trainees must know about the management of prescribed medicines, long-term conditions and common ailments. I would expect this to cover allergy in its broadest sense of both short and long duration. The assessment standards under C2 (below) would also cover this. The knowledge requirements under C2 deal with inhalers, which are integral to asthma treatment.
C2 Assessment requirements
Evidence that your trainee provides for assessment should include: — proof that she has been involved in the provision of pharmaceutical services in both community and hospital practice. 382 allergy: evidence
— proof that she has provided advice or supplied non-prescribed medicines for a wide range of conditions, including those aVecting: — the respiratory tract; — the gastro-intestinal tract; — the oropharynx; — the skin; — the ear(s); — the eye(s); — musculoskeletal and connective tissue; — women; — babies and children; — elderly patients; — patients with long term health management needs.
C2 Knowledge requirements Most of the knowledge represented by the whole registration examination syllabus is needed to underpin these standards. In addition, your trainee must show that she has a working knowledge of, and can apply, the following: Compliance aids—availability and use. Use of inhalers and other devices. Dispensing for residential and nursing homes. Emergency first aid. Government healthcare priorities. Local healthcare priorities. Patient information leaflets. How to evaluate literature and data. Referral agencies in emergency or for provision of further advice. Roles of healthcare professionals. Sale of medicine protocol in your pharmacy (where the pharmacy sells medicines). Techniques for eVective questioning. Information sources. It must be remembered that none of the Performance Standards should be viewed in isolation, a trainee would not learn about inhalers in isolation—they would also learn about providing information to the patient about asthma management. I have attached the full list of Performance Standards including the underpinning assessment and knowledge requirements for your information.
APPENDIX 3
Additional References—Pharmacists and Allergy/Allergic Conditions
Pharmacy practice GSK Website www.pharmassist.gsk.co.uk/en120.htm Carr A et al. A pilot study of a community pharmacist intervention to promote the eVective use of emollients in childhood eczema. Pharmaceutical Journal 2007; 278: 319–322, www.pjonline.com/pdf/papers/pj– 20070317–childhoodeczema.pdf Dawn G. Allergy—Reacting to reactions. Independent Community Pharmacist 2006; Apr: 16–19. Focus on Customer Care—Discussion subject: airborne allergies. Pharmacy Magazine 2004; 4: 40–41. allergy: evidence 383
Allen, M. Scratch and sniV. Pharmacy Magazine 2005; 7: 40–41. GeoVrey C Wall; Lisa Peters; Catherine B Leaders; James A Wille. Pharmacist-Managed Service Providing Penicillin Allergy Skin Tests. American Journal of Health-System Pharmacy. Posted 07/02/2004.
Education RPSGB Pre-registration Performance Standards http://www.rpsgb.org.uk/pdfs/preregtrwb06-07.pdf
Centre for Pharmacy Postgraduate Education courses: Skin Conditions, the Management and treatment of http://www.cppe.manchester.ac.uk/Bookings/ Details.asp?TemplateID%Dermat%2DD%2D02&OnTab%0&Format%D Pharmaceutical Care of the Eye http://www.cppe.manchester.ac.uk/Bookings/Details.asp?TemplateID% EYE%2DD%2D02&OnTab%0&Format%D
OTC Diagnostic Testing Royal Pharmaceutical Society. RPS e-PIC References on; Diagnostic testing in community pharmacy www.rpsgb.rpsgb.org/pdfs/rpsepicdiagest.pdf Consulting areas for Superdrug stores. Pharmaceutical Journal. 2003: 270: 465 http://www.pjonline.com/ Editorial/20030405/news/superdrug.html Moss oVers food intolerance tests. Chemist-and-Druggist 2002; 257: 20. Home allergy test kits for asthmatics. Chemist-and-Druggist 2002; 257: 28. Imutest home allergy test. Pharmaceutical-Journal 2001; 267: 48. Lloyds oVers food intolerance tests. Pharmaceutical Journal 2001; 266: 243.
APPENDIX 4
Additional Information on Diagnostic Tests for Allergies Consulting areas for Superdrug stores, Pharmaceutical-Journal 2003: 270: 465 (5 April). Superdrug is to introduce screened consulting areas to its stores following positive feedback from customers about the 20 stores that have private consulting rooms. Superdrug currently uses its consulting rooms for services from blood pressure monitoring to allergy testing. http://www.pjonline.com/Editorial/20030405/news/ superdrug.html Moss oVers food intolerance tests, Chemist-and-Druggist 2002: 257: 20 (20 April). Moss Pharmacy is oVering food intolerance and allergy tests in its 800 branches. The tests are approved by the British Allergy Foundation and produced by York Nutritional Laboratories. Home allergy test kits for asthmatics, Chemist-and-Druggist 2002: 257: 28 (16 March). A range of home test kits has been designed to help asthma suVerers to diagnose their specific allergies. Individual test kits have also been developed to confirm cat, house dustmite, egg, milk and pollen sensitivity. Imutest home allergy test, Pharmaceutical-Journal 2001: 267 (14 July): 48. Clinical Diagnostic Chemicals has launched Imutest, a range of six home testing kits for checking sensitivity to allergens. Imutest Allergy Check is for checking patients’ sensitivity to allergens and is useful in those who have no idea what the causes of their symptoms are. Other products in the range test for five of the most common allergies: cat, egg, hayfever, house dust mite and milk. An allergy care nurse is available to provide support for users of Imutest. Lloyds oVers food intolerance tests. Pharmaceutical-Journal 2001: 266 (24 February): 243. Lloyds Pharmacy Ltd is oVering its customers a food intolerance testing service which will allow them to change their diets to avoid foods they might be allergic to. Two types of test service are available. A 40-food screen (£99 sterling) tests groups of foods, such as citrus fruits, for reactions and provides results for the most commonly eaten foods. A 93-food screen (£245 sterling) oVers more precise measurements for individual foods. The food testing is undertaken by York Nutritional Laboratory Ltd. 384 allergy: evidence
Unfortunately there is not a comprehensive list of diagnostic tests available for allergies; some of the products available are: Home allergy test kit (Clinical Diagnostic Chemicals). Imutest self tests for allergy (Clinical Diagnostic Chemicals). Yorktest (Yorktest Laboratories). Food Allergy and Food intolerance test kits (www.mypharmacy.co.uk—testing is carried out by Exeter Nutritional Clinic).
Memorandum by The Royal College of Midwives The Royal College of Midwives (RCM) is the professional organisation and trade union representing 95 per cent of all practising midwives in the United Kingdom. Virtually all practising midwives work within the NHS, and the RCM is recognised in every Trust that provides a midwifery service.
Comments The key issue here is about reducing the risks of a child developing an allergic condition.
Hygiene — To regularly vacuum carpets and wash floors. Preferable to have simple wooden/laminate floors that can be easily washed—most family homes with young children now have this; this is a trend. — Avoid quilts/pillows made of feathers or polystyrene materials. — Consider the type of mattress that the child sleeps on and change regularly as can be aVorded/ possible. Reducing the collection of dust mites in mattresses/carpets etc.
Clothing — Cotton is advisable—avoid nylon as far as possible. — Bed linen/sheets—should consider cotton. — Regular change of bed linen. — Wash clothing and bed linen with non-bio washing powder.
Skin Care — Simple, non-perfumed soap/lotion for washing/bathing.
Environment — Caution/avoidance of pollen laden areas in high season. — Caution around pets!!! — Avoid smoking in the home or near children/do not take children to smoke filled environments.
Foods — Exclusive breastfeeding for the first six months without the introduction of supplements or solid foods. Breast feeding contains specific immunological properties; while this may to a certain extent protect children from certain diseases, especially asthma, the home and environmental factors play a significant part. Parents can continue on to two years if they are able to; especially if the child is diagnosed with an allergy or there is a familial history of allergies/asthma. — Avoid the early introduction of cow’s milk, particularly below six months. — Introduce child to solid foods from family’s own diet/foods after six months. It is therefore important that family chooses/eats healthy/fresh food with fewer additives, colours etc. — Caution if familial history of nut allergies. allergy: evidence 385
— Parents should not give their children replacement foods/products/cut out dairy unless they have been diagnosed as having specific food allergies by a physician. — If they suspect that the child has symptoms similar to allergies; always consult a doctor/seek specialist medical advice and not try to self-treat.
Prevalence — The evidence is suggesting 25–30 per cent. — The most common allergies are around foods; lactose intolerance nut and other minor foods. However, parents should not self-treat/give replacement foods which can result in sensitisation of the child. — Other allergies include atopic diseases such as eczema, allergic rhinitis and asthma.
Education/Treatment/Gaps — Needs education particularly around foods/healthy eating and environmental factors. Good public health education on how to reduce risks of allergies. — Referral for specialist medical opinion—treatment should be dependent on the allergy and its causes.
Gaps — Late diagnosis as parents attempt to self-diagnose particularly around foods or have their children sensitised/desensitised by non-medical specialists. — Poor/lack of knowledge.
Memorandum by the Wellcome Trust 1. The Wellcome Trust is pleased to make a response to the House of Lords Science and Technology Committee call for evidence on allergy and allergic diseases. 2. The Wellcome Trust is an independent research-funding charity, established under the will of Sir Henry Wellcome in 1936. It is funded from a private endowment, which is managed with long-term sustainability and growth in mind. The Trust is the second largest biomedical research funding foundation in the world with a mission to “foster and promote research with the aim of improving human and animal health”. 3. The Trust has funded over £20 million of research into allergies and allergic diseases since 2000, through a number of its funding streams. 4. A wide range of academics and research centres have been supported by the Trust in this field. As requested by the Clerk of the Committee, we would like to draw the Committee’s attention to some individuals who we feel would oVer valuable insight into allergies and allergic diseases. The Trust has also supported the majority of the researchers that have been contacted by the Committee namely: — Professor Stephen Holgate; — Dr Seif Shaheen; — Professor Tim Williams; — Professor Tak Lee; — Dr Pamela Ewan; — Dr Glenis Scadding; — Dr Clive Robinson; — Professor John Britton; — Professor Anthony Frew; — Professor Adnan Custovic; and — Professor Douglas Robinson. 5. Outlined below are details of the researchers and their current projects supported by the Wellcome Trust. The Trust would be happy to supply further details about these projects if the Committee feels it would be useful. 386 allergy: evidence
6. The MRC-Asthma UK Centre in Allergic Mechanisms of Asthma at King’s College London and Imperial College London
Dr Clare Lloyd, Imperial College London University
Current research Dr Lloyd and her colleagues have developed a murine model of allergen induced airway inflammation and remodelling, and used this model to identify key interactions leading to the development of pathology. The model recapitulates many of the features characteristic of the human disease, including eosinophilic inflammation, airway hyperresponsiveness, mucus production, extracellular matrix deposition, airway secretion. Importantly, the changes to smooth muscle cell proliferation, and TGF to airway structure were sustained in the absence of further allergen challenge. Current studies of the team aim to delineate molecular and cellular pathways involved in the resolution of allergen induced airway inflammation and remodelling. They plan to manipulate pathways thought to play a regulatory role in the immune system in order to promote resolution of established airway remodelling. The eVects of these manipulations on development of AHR, inflammation, and parameters of airway remodelling such as collagen deposition and mucus production will then be assessed. In addition they are investigating the contribution of resident lung cells to airway remodelling. They will investigate the ontogeny of fibroblasts during the development of airway remodelling in vivo. Dr Lloyd is a current Wellcome Trust Senior Basic fellow (from 1999).
7. Professor Peter Friedmann, Professor of Dermatology, University of Southampton
Current research Dr Friedmann’s current research includes the: investigation of xenobiotic disposition in the development of allergic contact hypersensitivity; mechanisms of adverse reactions to therapeutic drugs and contact sensitisers; the generation of inflammatory mediators in skin—a microdialysis study; and the functional role of vasoactive mediators in allergic contact hypersensitivity responses in human skin in vivo. Prof Friedmann was awarded in 2004, a Wellcome Trust Science Research Investment Fund (SRIF), for a new superdivision of Infection, Allergy, Inflammation and Repair at Southampton General Hospital.
8. Professor Hugh Miller, University of Edinburgh
Current research The Miller Group’s primary research interest is in mast cells, their recruitment to the epithelium and how mucosal mast cell specific proteases, which are produced in abundance by rodents, function within the aVected mucosa. A key role for the proteases may be in regulating epithelial tight junctions, thus controlling epithelial permeability. Further to this, they are employing current methods for global analysis of gene transcription (micro-arrays) and protein expression (proteomics) to discover novel molecules and patterns of expression in allergic reactions and parasite rejection. A group of candidate molecules, including intelectin, resistin-like molecule beta and acidic mammalian chitinase are being studied in more detail. By understanding how natural immunity to parasites works, their hope is to be in a better position to augment these processes and design eVective vaccines. Professor Miller has received Wellcome Programme Grants to support this work. September 2006